老年患者肺叶切除围手术期及并发症的处理

目的总结高龄病人肺叶切除外科经验，进一步降低手术后并发症和死亡率，提高外科手术治疗效果。方法1990—2004年间收治65例60岁以上病人行肺叶切除术。其中肺癌病人40例，肺良性肿瘤7例，肺脓肿4例，肺霉菌球并支气管扩张5例，肺结核球6例，炎性假瘤3例。结果术后心脏并发症13例，肺部并发症12例，术后3例3天后死于心肌梗死，1例死于呼吸衰竭。本组早期死亡率6．1％。结论对高龄肺部疾病患者的手术应持积极态度，降低术后并发症和死亡率的关键在于早期诊断和认真做好围手术期处理。     

外伤性迟发性颅内血肿临床分析

目的:探讨外伤性迟发性颅内血肿的早期诊断及治疗效果。方法:回顾分析本院收治的121例外伤性迟发性颅内血肿的发生机理、早期诊断和治疗效果。结果:对幕下血肿大于10ml,幕上血肿大于30ml且中线移位明显者75例施行开颅血肿清除加去骨瓣减压术,效果良好53例,重残5例,死亡17例,死亡率22.7%。而46例血肿较小、中线移位不明显者行非手术治疗,效果良好35例,重残8例,死亡3例,死亡率6.5%。结论:早期诊断能明显提高外伤性迟发性颅内血肿的治疗效果,而动态CT监测是早期诊断外伤性迟发性颅内血肿的关键。     

迟发性腹腔室隔综合征的诊断和治疗

目的探讨重症急性胰腺炎病人并发迟发性腹腔室隔综合征的诊断和治疗方法。方法回顾性分析301例重症急性胰腺炎患者，5例在感染期发生迟发性腹腔室隔综合征。2例早期患者采用非手术治疗，3例后期患者一经诊断后，即行手术减压治疗。结果非手术治疗患者．均于迟发性腹腔室隔综合征发生后1～2d死亡；手术患者，均得以存活，总体死亡率达40％。结论重症急性胰腺炎病人并发迟发性腹腔室隔综合征具有极高的死亡率；早期诊断并及时治疗迟发性腹腔室隔综合征对抢救生命具有重要意义。     

老年人结肠癌并梗阻38例诊治体会

目的探讨老年人结肠癌并急性梗阻的诊断与治疗。方法回顾性分析2002年至2005年38例60岁以上结肠癌并急性梗阻病人的外科治疗资料。结果38例中Ⅰ期切除26例，Ⅱ期切除7例，捷径手术5例38例中有伴发病者32例，占84．2％，术后并发症发生率高达52．7％，手术死亡率为10．5％。结论手术切除是高龄结肠癌病人最好治疗方法，应早期诊断，早期治疗，合理处理并存病。充分的肠道准备，适当的麻醉和手术方式，有效的预防和治疗并发症是提高疗效的关键。     

Gardner综合征的诊治(附一家系8例病人的报道)

目的:通过对一个Gardner综合征家系的追踪调查,明确该病的诊断、治疗原则,使更多的临床工作者认识、了解该病,提高治愈率,降低死亡率。方法:利用查体、内镜(纤维结肠镜、纤维胃镜)、骨骼X线平片、病理活检等方法对一个疑似Gardner综合征家系的42位成员进行筛查。结果:通过筛查共确诊家系中患该病者8例(发病率19.0%),其中男女各4例;年龄12～81岁。病人中出现结肠腺瘤性息肉病变者8例(100%),其中发生恶变者为3例(37.5%),平均癌变年龄35.9岁。病人中出现硬纤维瘤病变者共3例(37.5%),均为已生育后的女性,3例的病变部位均位于腹部(2例单纯性腹壁硬纤维瘤,1例除腹壁外还有腹腔硬纤维瘤病变)。病人中出现骨损害病变者2例,皆为男性青少年,部位在颅骨及颌面骨,呈多发性。8例病人中死亡3例(死亡率37.5%),2例死于息肉癌变,1例死于腹腔内硬纤维瘤病。结论:Gardner综合征病人的诊断意义不仅在于对患病个体的治疗,更重要的是对家系中其他成员的筛查、诊断,尤其是对无症状病人和尚未出现严重并发症的病人。早期诊断的意义在于早期应用药物、放疗等方法阻止或延缓结肠腺瘤性息肉病的发展和癌变,从而推后手术时间,防止因手术创伤导致腹壁和(或)腹腔硬纤维瘤病的发生、发展。合理的控制和治疗结肠腺瘤性息肉及癌变,恰当的治疗腹部硬纤维瘤病尤其是腹腔和肠系膜硬纤维瘤病,是提高病人术后生存率、降低死亡率的重要手段。     

动脉瘤性蛛网膜下腔出血的早期诊断及治疗

目的探讨动脉瘤性蛛网膜下腔出血（SAH）的早期诊断方法及治疗原则,并客观评价其治疗效果。方法对SAH患者采用影像学检查,结合病史、临床表现进行早期病因诊断;并对96例动脉瘤早期采用电解可脱性弹簧圈进行囊内栓塞;术后早期对症治疗。结果96个动脉瘤均被早期诊断并成功栓塞,其中100％闭塞者83个,95％闭塞者8个,90％闭塞者5个。术中并发动脉瘤破裂3例;并发脑血管痉挛5例;术后1例弹簧圈末端逸出;3例复发者均经二次补充电解可脱性弹圈（GDC）栓塞治愈。全组出现与栓塞技术相关的并发症9例;与SAH有关的永久性后遗症13例（13．5％）。Glasgow预后评分：Ⅰ级77例、Ⅱ级7例、Ⅲ级6例、Ⅳ级3例、Ⅴ级3例,死亡率3．1％。结论对破裂的动脉瘤性SAH进行早期病因学诊断,并采用电解可脱性弹簧圈进行动脉瘤囊内栓塞,术后积极对症治疗是提高动脉瘤性SAH治愈率和降低死亡率、致残率的重要方法。     

急性肠系膜静脉血栓形成的诊断和治疗

目的探讨肠系膜静脉血栓形成(MVT)的诊断和治疗。方法总结11例肠系膜静脉血栓形成病人的诊治经验，结合文献分析MVT的发病机理、临床特点、诊断和治疗。结果11例病人均以急腹症或肠梗阻收住院，术前明确诊断者8例，其中发病24h内确诊者仅2例。全部患者行手术治疗，均治愈，随访无复发。结论提高对该病的认识是早期诊断的关键，及时手术行肠切除是治疗本病的有效方法，切除足够范围肠段及早期抗凝治疗是预防复发的根本措施。     

成人先天性胆总管囊肿的诊断及治疗

目的 探讨成人先天性胆总管囊肿的诊断和治疗。方法 对收治的53例成人先天性胆总管囊肿病人进行分析。B超诊断正确率90．57％(48／53)。49例行囊肿切除和肝总管空肠Roux-Y吻合术。2例因癌变分别行肝门胆管癌根治术和胰十二指肠切除术。手术死亡率1．89％。结果 随访43例，随访率81．13％，平均随访32个月，约90％的病人能从事一般体力劳动，未观察到恶变者。结论 B超应作为先天性胆总管囊肿的首选检查，囊肿切除和肝总管空肠Roux-Y吻合术应作为首选术式，早期诊断，早期治疗，控制囊肿发展，减少并发症是改善先天性胆总管囊肿的关键。     

小儿外伤性硬膜外血肿的诊治

目的 探讨小儿外伤性硬膜外血肿的临床特点、手术方法及治疗效果。方法 对本院自1944年1月至2002年5月收治的5(例小儿外伤性EDH，进行回顾性分析。手术治疗49例，保守1例。结果 全部病例中存活49例，死亡1例。其中重残1例，死亡率2％。结论 早期诊断、及时正确的治疗，是小儿外伤性硬膜外血肿患降低死亡率致残率、提高治愈率的关键。     

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目的　总结术后早期炎性肠梗阻的治疗经验 ,提出诊断标准、治疗和预防措施。方法　回顾 73例炎性肠梗阻病人的治疗方法 ,包括禁食、胃肠减压、全肠外营养、糖皮质激素和生长抑素的应用。结果　 73例病人中治愈 72例 ,平均治愈时间为 (2 6 4± 11 6 )天 ,1例病人治愈后 18个月因机械性肠梗阻再次手术治愈 ,其余病人未再进行手术治疗 ,无复发者。结论　采用非手术疗法治疗术后早期炎性肠梗阻效果满意 ,并发症少 ,安全。手术治疗并发症多 ,疗效差。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.