双U形回肠代膀胱术的初步研究(附20例报告)

目的　改良回肠代膀胱成形方法 ,更好地解决膀胱全切术后贮尿和排尿问题。　方法　 2 0例膀胱癌患者行膀胱全切后 ,采用双U形方法作原位回肠代膀胱。于对系膜缘剖开肠管 ,肠片左右U形排列 ,连续缝合内侧缘 ;上下U形对折缝合成球形膀胱 ,上下U形缝合前行输尿管新膀胱再植和新膀胱尿道吻合。　结果　成形手术时间 (90± 15 )min。无严重并发症 ,无围手术期或术后早期死亡。术后随访 6～ 4 8个月 ,平均 2 5个月。患者控尿、排尿满意 ,2 0例 (10 0 % )白天控尿 ,夜间轻度尿失禁或遗尿 6例 (30 % ) ;1例男性患者出现排尿困难 ,行TUR解除。贮尿囊容量 2 5 0～ 4 5 0ml,平均 340ml,剩余尿 0～ 4 0ml。　结论　双U形回肠代膀胱术操作简便 ,新膀胱容量大、压力低 ,术后并发症发生率低。     

原位M形回肠代膀胱术42例报告

目的　评价原位M形回肠代膀胱的疗效。　方法　男性膀胱恶性肿瘤患者 4 2例 ,腹膜外切除膀胱前列腺 ,截取 4 5～ 5 0cm回肠纵行剖开后M形折叠形成贮尿囊 ,输尿管插入贮尿囊内 1cm作吻合 ,贮尿囊底部与尿道 6针吻合 ,将贮尿囊完全置于腹膜外。　结果　本组 4 2例 ,术后随访12～ 96个月 ,平均 4 4个月。白天控尿良好者 38例 (90 .5 % ) ,夜间控尿良好者 36例 (85 .7% )。术后 12个月代膀胱容量 (36 1± 4 8)ml,最大排尿压 (86 .8± 2 1.4 )cmH2 O(1cmH2 O =0 .0 98kPa) ,最大尿流率(18.4± 6 .1)ml/s,无明显输尿管梗阻及返流。未发现尿道残端复发肿瘤。　结论　腹膜外切除膀胱可减少腹腔被肿瘤污染 ,避免肠管进入盆腔而影响手术操作。插入式输尿管吻合法 ,操作简单 ,术后形成小乳头有良好的抗返流作用 ,输尿管狭窄发生率低。代膀胱置于腹膜外 ,可减少肠粘连、肠梗阻、输尿管梗阻、腹腔内感染等并发症。改良后的原位回肠代膀胱术式 ,具有手术操作简单、术后并发症少、功能良好的特点 ,代膀胱在位置、形态、容量及输尿管抗返流等方面均接近正常膀胱。     

改良低压回肠代膀胱术的疗效评价

目的 总结改良原位低压回肠代膀胱术的疗效及患者生活质量。方法 膀胱癌患者53例，平均年龄61岁，均施行根治性膀胱全切术。截取末端35—45cm回肠，“U”形缝合形成代“膀胱”，并与输尿管形成抗返流的“乳头”缝合。结果 术后所有患者血生化及电解质均正常，随访3—6个月，51例患者白天完全可控排尿，完全夜间可控制排尿25例。47例无残余尿，5例有残余尿20-35mL。结论 改良低压回肠代膀胱术，膀胱容量大、压力低、无返流、效果好、无吸收性酸中毒，患者白天均能够控制尿液，夜间需定时排尿，生活质量高，多数患者满意。     

扩大功能性直肠膀胱

作者于1988年8月至1990年3月,为16例女病人做了扩大的功能性直肠膀胱,其中8例根治性膀胱全切,2例过去做过腹壁尿瘘。手术方法:标准膀胱全切后,游离45cm末段回肠,远端30cm沿对系膜缘剖开,作“U”形折迭,切缘一侧严密缝合,另侧开放,待与直肠吻合;未切开的近端回肠向远侧套入7cm,形成抗逆流乳头。左侧输尿管从肠系膜下拉向右侧,两输尿管末端分别纵行切开1.5cm,互相吻合,然后与回肠近端吻合(WallaceⅠ式)。距肛门4-5cm处纵行切开直肠前壁15cm,将乙状结肠顺蠕动方向套入6cm,形成套叠乳头,缝合固定,防止结肠返流。输尿管导管由肛门拉出,同时以30F导管引流直肠。回肠囊未缝侧缘与切开的直肠边缘做两排缝线缝合。最后做临时性结肠造     

Studer原位尿流改道在女性膀胱癌治疗中的应用

目的 评价Studer原位尿流改道治疗女性浸润性膀胱癌的临床效果。方法 回顾性分析1998年5月至2005年2月20例女性膀胱全切、Studer原位尿流改道患者的资料。患者年龄48～65岁，平均56岁。膀胱移行细胞癌19例、腺癌1例。术中取回肠袢约65cm，其中近端10～12cm作为抗返流输入道，远端53-55cmU形折返缝合成球形肠膀胱。结果 手术时间4．5～8．0h，平均6．0h。输血量300-600ml，平均465ml。随访4～84个月，平均25个月。围手术期患者无死亡。早期并发症有黏液阻塞尿道6例、漏尿1例、腹泻4例、肺部感染2例。术后2年肠膀胱内结石1例，于腔镜下取出。术后肠膀胱容量约140ml，术后3个月平均390ml，1年后平均500ml。患者均利用腹压排尿，剩余尿0～49ml，平均19m1。白天排尿4～6次，平均4．5次，夜间0～4次，平均2次。白天控尿良好，夜间尿失禁1例，需2块尿垫。术后1年尿动力学检查13例：充盈期膀胱压力19～28cmH2O，最大尿流率12～19ml／s。17例术后3个月尿路造影示肠膀胱形态良好，无输尿管返流及上尿路扩张，3例患者出现轻微返流，未引起上尿路扩张，B超测定肾皮质厚度无变化。肾功能和血电解质结果正常，无盆腔和尿道肿瘤复发。结论 Studer原位尿流改道治疗女性浸润性膀胱癌患者并发症少，排尿和控尿功能满意。     

Bricker术后TU-Pouch尿流复道(附1例报告并文献复习)

目的:探讨根治性全膀胱切除术术后尿流复道关键技术的设计以及适应证的选择。方法:我们对1例行根治性全膀胱切除+回肠膀胱术后患者施行回肠+乙状结肠原位新膀胱术以实现尿流复道,术前准备主要包括患者心理准备、肿瘤预后的相关检查和尿道括约肌功能判断。金属尿道探子支撑下分离尿道残端以备用。选取乙状结肠20cm纵行剖开形成肠袋,作为新膀胱的"U"部分。切除Bricker腹壁造瘘口,并以此段回肠形成半套叠状抗反流结构及新膀胱的"T"部分。"T"肠袋与"U"肠袋侧-侧吻合,共同形成"TU-Pouch"新膀胱。新膀胱最低点与尿道残端吻合。结果:术后随访1年,患者自行排尿通畅,尿量350~400ml/次,日间排尿3~5次,控尿良好;夜间排尿2~3次,轻度尿失禁。逆行膀胱造影未见造影剂向输尿管反流,静脉肾盂造影见双侧肾盂输尿管显影良好,无积水。结论:全膀胱切除术后的尿流复道手术是复杂的、高难度和高风险手术,需严格掌握适应证。有效的抗反流机制和良好的控尿功能是决定手术是否成功、影响患者术后生活质量的关键。     

正位可控去带盲结肠膀胱加回肠抗反流术

目的：探讨正位可控去带盲结肠膀胱加回肠抗反流术的临床效果。方法：采用膀胱全切正位可控去带盲结肠膀胱加末段回肠抗反流术治疗膀胱癌20例。结果：随访9～42个月，白天均可控制排尿，14例夜间能白控排尿，6例夜间有尿失禁。尿动力学检查：12个月贮尿囊平均最大容量350ml，平均最大囊内压3．16kPa，剩余尿量为16ml，平均最大尿流率19．2ml／s。贮尿囊造影及IVU显示2例有双侧输尿管反流，无输尿管狭窄和肾积水。血电解质及肾功能正常。结论：正位可控去带盲结肠膀胱加末段回肠抗反流术操作简单，并发症少，疗效好，是一种较理想的膀胱替代术。     

改良膀胱全切原位W形回肠膀胱术26例报告

目的评价改良膀胱全切原位W形回肠膀胱术的临床疗效。方法对26例膀胱癌患者行逆行和顺行相结合的全膀胱切除方法，截取40cm带蒂回肠，对肠系膜纵行剖开后W形折叠，缝制成新膀胱，输尿管以乳头法种植于膀胱“三角区”，将贮尿囊完全置于腹膜外；术后随访患者恢复和排尿情况，定期复查生化指标、B超和膀胱排尿造影。结果患者术后均康复，平均随访18个月，白天控尿良好20例，夜间控尿良好18例；5例有不同程度的肾积水和肾功能异常，其中1例出现双肾积水，均行膀胱排尿造影除外返流；无低钾血症和酸中毒。结论改良膀胱全切原位W形回肠膀胱术，具有手术简单、术后并发症少及代膀胱功能良好的特点，是治疗浸润性膀胱癌的理想方法。     

低张力Roux-y肠代膀胱术13例报告

目的总结低张力抗返流Roux-y肠代膀胱术的疗效。方法采用改良输尿管-结肠、结肠-直肠吻合术对12例膀胱癌和1例膀胱阴道瘘患者行低张力Roux-y肠代膀胱术。于Roux—y吻合口上方1．5cm作抗返流瓣，输尿管与结肠行Leadbetter法吻合，去肠管化做乙状结肠储尿囊。术后观察电解质、酸碱平衡和排尿情况。结果随访0．5～5．0年，除2例偶有发热外，患者无肾积水，电解质和酸碱平衡正常，无尿失禁。结论低张力抗尿粪返流Roux-y肠代膀胱术是一种创伤较小、并发症较少的肠代膀胱术。     

腹腔镜下根治性膀胱切除回肠新膀胱术（附15例报告）

目的介绍腹腔镜下根治性膀胱切除回肠新膀胱术的方法及经验。方法本组15例，均为男性，年龄45～62岁，平均54岁。术前均明确诊断为浸润性膀胱癌。采用腹腔镜下行膀胱癌根治性切除，然后取长约40cm回肠于体外缝制贮尿囊及输尿管贮尿囊吻合，体内行贮尿囊尿道吻合术。结果手术时间5．5～8h，平均6．5h；出血量200～1100ml，平均550ml。术后8周静脉尿路造影以及代膀胱造影检查显示：双肾显影良好，无输尿管返流及梗阻，代膀胱充盈良好，容量约300ml。术后3个月全部患者日间控尿良好，7例患者夜间控尿良好，夜间排尿2～3次。结论腹腔镜下膀胱全切除、体外建成贮尿囊及输尿管再植、体内贮尿囊尿道吻合术创伤小、出血少、术后尿控率高、恢复快。     

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.     

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.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

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.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.