术前门静脉栓塞在Ⅳ型肝门胆管癌的应用价值探讨

目的 探讨术前门静脉栓塞（portal vein embolization,PVE）在Ⅳ型肝门胆管癌中的应用价值。方法 对2010年12月至2011年2月中国医科大学附属盛京医院肝胆脾外科术前行PVE的2例Ⅳ型肝门胆管癌进行分析。结果 2例均行经皮经肝胆道引流（percutaneous transhepatic biliary drainage,PTBD）解除梗阻性黄疸,PVE诱导剩余肝体积代偿增生后,未来剩余肝（future liver remnant,FLR ）与全肝体积（total liver volume,TLV）之比分别为49.7%、43.7%,较PVE前分别增加7.9%,5.4%。2例行右半肝及尾状叶切除、肝门胆管癌根治术,手术顺利,术后恢复良好,至今分别无瘤生存18、19个月。 结论 PVE能够安全有效增加FLR,从而增加手术安全性,降低术后肝衰竭的发生率。     

经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术治疗余肝体积不足肝癌及胆管癌3例报告

目的 探讨经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术（percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy,PAPEP）替代联合肝脏分隔和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy, ALPPS）治疗剩余肝体积（future liver remnant,FLR）不足肝癌和胆管癌的可行性和安全性。方法 回顾性分析2015年7-9月浙江省人民医院肝胆胰外科应用PAPEP治疗FLR不足的2例原发性肝癌和1例肝门部胆管癌的临床资料。先超声引导下经皮微波消融分隔预留侧和切除侧肝实质（percutaneous microwave ablation liver partition,PMA）,PMA后1~3 d行门静脉栓塞术（portal vein embolization,PVE）,PVE后10~13 d测量FLR,术前系统评估后限期肝切除术：2例肝癌分别行肝右三叶和右尾叶切除术、扩大右半肝切除术,1例肝门部胆管癌行肝右三叶和尾叶切除、肝肠内引流术。结果 PMA前3例标准全肝体积（standard liver volume,SLV）分别为1231.2mL、1202.9mL、1217.1mL,FLR分别为355.6 mL、383.4 mL、385.0 mL,FLR/SLV分别为28.9%、31.9%、31.6%。PMA时间118~132 min, PVE时间158~180 min,PMA或PVE术后病人低热经对症处理好转,肝功能无明显变化。PMA+PVE后10~13 d FLR分别为502.1 mL、527.4 mL、476.3 mL,较术前分别增大41.2%、37.6%、23.7%。肝切除术时间230~440 min,术中出血120~1800 mL。肝门部胆管癌术后并发膈下脓肿,经穿刺后治愈;1例肝癌术后并发腹水、黄疸,经内科治疗后治愈,术后住院时间15~40 d。 结论 PAPEP有望代替ALPPS治疗剩余肝体积不足的肝癌或肝门部胆管癌。     

术前门静脉栓塞术在肝门部胆管癌扩大肝切除术中的应用研究

目的 评价肝门部胆管癌扩大肝切除术前行门静脉栓塞术的有效性及安全性,比较门静脉栓塞手术切除术与非门静脉栓塞手术切除术后结果.方法 2007年5月至2010年10月收治肝门部胆管癌患者57例,分为两组,将预保留肝占全肝体积＜50％、术前接受门静脉栓塞(PVE)者设为PVE组(26例),男16例,女10例,年龄(56.48...     

肝门部胆管癌术前行门静脉栓塞16例分析

目的 探讨未来残余肝较小的肝门部胆管癌病人行门静脉栓塞是否安全有效。 方法 对2007年1月至2009年3月第二军医大学附属东方肝胆外科医院拟行大部肝切除、未来残余肝/全肝体积（FLR/ TLV）比<50%的16例接受钢圈门静脉栓塞（portal vein embolization,PVE）的临床资料进行分析。 结果 术前16例（PVE组）因肝功能损害、FLR/TLV < 50%者行PVE治疗,33例（非PVE组）FLR/TLV > 50%者行肿瘤联合肝切除。PVE后3例出现并发症,原因为胆漏和钢圈移位,但未推迟肝切除术日期。16例PVE中1例合并肝硬化出现非栓塞肝叶增生不全而未能接受外科治疗,2例术中发现肿瘤进展、腹膜播散未能接受肝切除术,余13例（81.3%）行联合肝切除的肿瘤切除术。PVE组和非PVE组的手术并发症发生率分别为69.2%及63.6%,手术死亡率为0及9.1%。二者相比差异无统计学意义。结论 PVE能安全、有效地诱导肝门胆管癌术前未来残余肝增生。     

选择性门静脉栓塞在肝叶切除术中的临床应用

手术切除肝脏巨大肿瘤或多发性转移瘤的安全性已大为提高,但半肝或肝三叶切除术后残余肝脏的功能不全仍困扰着外科医师。1986年,日本学者Kinoshita等提出选择性门静脉栓塞（portal vein embolization,PVE）作为扩大肝切除术前准备,并应用于肝癌的治疗。PVE使栓塞侧肝叶萎缩,而非栓塞侧肝叶代偿性增生,     

肝大部切除术前选择性门静脉栓塞(PVE)的临床应用

肝大部分切除（半肝或三叶肝切除）术后所保存的残余肝脏容积（remnant liver volume，RLV）不足是术后并发肝功能衰竭的主要危险因素。正常成人切除超过70％有功能的肝组织是发生术后肝衰竭的高危因素。术前选择性门静脉栓塞（portal vein embolization，PVE）可使未栓塞侧的肝组织增生肥大，增大肝脏容积；栓塞侧肝组织萎缩，肿瘤可缩小。使原来不能耐受手术切除的部分病例可以耐受手术切除，提高肝切除手术的安全性，并且不会增加使肝切除手术难度。PVE还可减少肿瘤通过门静脉系统发生转移的机会和增加肝动脉栓塞化疗的抗癌作用。本文就肝大部切除术前选择性门静脉栓塞的发展、原理、方法和临床应用作一综述。     

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目的探讨术前门静脉栓塞(portal vein embolization,PVE)在Ⅳ型肝门胆管癌中的应用价值。方法对2010年12月至2011年2月中国医科大学附属盛京医院肝胆脾外科术前行PVE的2例Ⅳ型肝门胆管癌进行分析。结果 2例均行经皮经肝胆道引流(percutaneous transhepatic biliary drainage,PTBD)解除梗阻性黄疸,PVE诱导剩余肝体积代偿增生后,未来剩余肝(future liver remnant,FLR)与全肝体积(total liver volume,TLV)之比分别为49.7%、43.7%,较PVE前分别增加7.9%,5.4%。2例行右半肝及尾状叶切除、肝门胆管癌根治术,手术顺利,术后恢复良好,至今分别无瘤生存18、19个月。结论 PVE能够安全有效增加FLR,从而增加手术安全性,降低术后肝衰竭的发生率。     

术前TAGM联合弹簧圈门静脉栓塞根治肝门胆管癌1例报告

正右侧侵犯为主的肝门胆管癌根治术多需要联合右半肝切除,可能会导致术后肝衰竭。近年来,计划性肝切除的策略备受关注,采用门静脉栓塞(portal vein embolization,PVE)的介入技术能诱导未来残余肝(future liver remnant,FLR)术前增生、降低肝衰风险~([1-3])。使用三丙烯酸酯明胶微球(tris-acryl gelatin microspheres,TAGM)作为末梢栓塞剂,联合近侧弹簧圈的PVE在国内鲜有报道。笔者单位1例尝试采用此技术治疗1例。报告如下。     

门静脉栓塞在肝切除术前的临床运用

门静脉栓塞（PortalVeinEmbolization,PVE）通过栓塞患侧肝脏门静脉,使其萎缩而对侧肝叶增生,从而增加术后残肝体积（remnantlivervolume,RLV）,扩大肝切除手术的适应证,提高了手术的安全性。目前临床主要应用于RLV过小而无法耐受肝叶切除术的肝肿瘤患者,现就PVE在肝癌治疗中的临床应用做一综述。     

联合肝叶切除治疗肝门部胆管癌

目的研究联合肝叶切除术治疗肝门部胆管癌的手术方式、并发症及疗效。方法回顾性分析2000年1月至2011年3月67例肝门部胆管癌患者临床资料。联合左半肝切除23例,右半肝切除9例,尾状叶切除3例,右三叶、右前叶切除各4例,姑息性切除15例,内引流术4例,经皮肝穿刺胆道引流外引流术5例。结果死亡1例,手术并发症发生率37．31％（25／67）。联合肝叶切除组术后中位生存时间为31．1个月,高于姑息性切除组（15．8个月）。联合肝叶切除组的1、3、5年存活率为78．5％、48．3％和29％,姑息性切除组的1、3、5年存活率为43．5％、6．8％、0。术后随访率67．16％（45／67）。结论肝门部胆管癌应积极手术切除治疗,对无明显手术禁忌证的患者行包括肿瘤切除的联合肝叶切除的扩大根治术可延长患者存活期;围手术期正确处理是减少术后并发症,提高患者生活质量和延长存活期的关键。     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

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.     

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.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

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.     

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.