胆胰分流消化道重建在胰十二指肠切除术中的应用

从1935年Whipple报道壶腹部肿瘤胰十二指肠切除后,胰十二指肠切除术(pancreaticoduodenectomy,PD)渐成为壶腹周围癌的标准治疗方法.近年来,由于手术熟练程度的改善、手术方法及围手术期管理等方面的改进,胰十二指肠切除术的病死率已明显地改善,但由于手术切除范围广泛、消化道重建等手术操作复杂,术后并发症仍有较高的发生率,其中胰瘘是其常见且严重的并发症,文献报道胰十二指肠切除术后胰瘘的发生率仍可达5%～10%,其中病死率甚至可达25%[1],其对患者的生存质量和预后都产生严重的影响.因此减少和预防胰瘘的发生仍是当前胰十二指肠切除术迫切需要解决的难题.     

胰十二指肠切除术治疗壶腹周围癌的临床价值(附144例报告)

目的探讨根治性胰十二指肠切除术在壶腹周围癌中的临床治疗价值。方法回顾性分析本院2005年03月至2011年03月外科手术治疗的144例AVC患者的临床资料,可分为姑息性手术组96例、手术切除组48例。结果手术切除组术后第1年、3年及5年生存率较姑息性手术组明显提高(P0.01),但其围手术期并发症发生率也明显升高(P0.05),70岁以上年龄的围手术期病死率与70岁以下患者比较差异无统计学意义(P0.05)。外科治疗的不同部位肿瘤中,胰头癌患者根治切除率较胆总管下端癌及十二指肠乳头癌患者显著性降低(P0.01),并且胰头癌患者第1年、3年、5年手术生存率也明显低于胆总管下端癌及十二指肠乳头癌患者(P0.05,P0.01)。术前减黄治疗组与术前未减黄治疗组的围手术期并发症发生率、死亡率、及第1年、3年、5年生存率比较差异无统计学意义(P0.05)。结论外科手术切除是治疗壶腹周围癌的重要手段,尤其根治性胰十二指肠切除术是治愈壶腹周围癌的唯一有效的治愈方法 ,受侵犯门静脉或肠系膜上静脉的联合切除,或联合半肝切除的扩大胰十二指肠切除术提高了治愈壶腹周围癌的机会。     

早期壶腹癌的局部切除治疗

目的 评估早期壶腹癌局部切除的可行性.方法 回顾性分析20年间共36例术后病理证实为Tl期(pTl)的壶腹癌,其中局部切除11例,胰十二指肠切除25例.对其术前和术中的诊断和分期进行评价,同时对不同手术方式的围手术期并发症及死亡率、住院时间、术后肿瘤复发及长期生存状况进行统计分析.结果 与胰十二指肠切除术相比,局部切除手术操作简单,围手术期并发症发生率低(P=0.031);但两组的术后住院时间(P=0.254)、围手术期死亡率(P=1.000)、术后无复发生存率(P=0.301)及长期生存率(P=0.289)之间相比差异均无统计学意义.结论 对于早期壶腹癌来说局部切除与胰十二指肠切除的治疗效果相当,且术后并发症发生率低,适用于手术风险较大或拒绝行胰十二指肠切除术的患者.     

捆绑式胰肠吻合的改良及其在老年壶腹周围癌中的应用

目的：总结改良捆绑式胰肠吻合技术在老年壶腹周围癌行根治性手术中的疗效。方法：回顾分析17例采用改良捆绑式胰肠吻合技术行根治性胰十二指肠切除的老年壶腹周围癌患者，观察术后并发症。结果：17例采用改良捆绑式胰肠吻合技术行根治性切除者无1例发生胰瘘，无围手术期死亡。全组病例的1年，3年，5年生存率分别为52．9％(9／17)，29．4％(5／17)及11．8(2／17)。结论：改良捆绑式胰肠吻合技术和恰当的围手术期处理，有助于减少老年壶腹周围癌患者术后胰瘘等并发症及降低病死率。     

壶腹周围肿瘤伴梗阻性黄疸术前减黄的指证及实施

正1壶腹周围肿瘤伴梗阻性黄疸现状及争议近年来,壶腹周围癌的发病率逐年升高,特别是胰头癌,已成为西方国家第四大致死原因。胰十二指肠切除术成为壶腹周围癌唯一的根治性治疗手段。随着现代外科技术的进步,胰十二指肠切除术的死亡率已由原先的20%下降到5%左右,但是围手术期的并发症仍然高达40%~75%[1]。恶性梗阻性黄疸是壶腹周围癌的常见临床症状,大多数壶腹周围癌患者在确诊时已经伴有梗阻性黄疸,这类     

Vater壶腹部周围癌胰十二指肠切除术后胰瘘的危险因素及对策

<正>Vater壶腹部周围癌是指胆胰壶腹周围2cm范围内的恶性肿瘤,包括胆总管下端癌、壶腹癌、十二指肠乳头癌和胰头癌。胰十二指肠切除术(pancreaticoduodenectomy,PD)是主要的根治性治疗手段。胰瘘(pancreatic fistula,PF)是PD常见的严重并发症之一。胰瘘的定义不尽相同,为了便于比较和国际交流,术后胰瘘国际研究小组规定,只要术后     

胰腺微创手术中胰腺残端处理

正胰十二指肠切除术(pancreaticoduodenectomy,PD)及胰体尾切除术(distal pancreatectomy,DP)是治疗壶腹周围肿瘤及胰体尾肿瘤的标准术式。此类术式区域解剖复杂,手术操作难度大,术后并发症较多。随着手术经验的积累及围术期管理水平的提高,围术期死亡率已明显下降,但术后并发症发生率仍居高不下,其中胰瘘是最常见且最严重的并发症之一,发生率高达10%～30%~([1])。     

壶腹周围癌合并糖尿病患者的围手术期处理

目的 探讨壶腹周围癌合并糖尿病患者的围手术期处理方法。方法 回顾性总结１９９６－１９９８年收治的２９例壶腹周围癌合并糖尿病患者的临床资料。结果 全部病例均手术治疗,其中胰十二指肠切除术１９例,均严格糖尿病处理,术前血糖控制在５．３￣７．６ｍｍｏｌ／Ｌ。围手术期疗效满意率为１００％,无手术死亡。结论：加强围手术期的处理可提高壶腹周围癌合并糖尿病病患者的手术耐受性降低术后并发症。     

手术步骤改进治疗壶腹周围癌49例体会

目的　探讨新的诊断和治疗技术对壶腹周围癌外科手术疗效的影响。方法　回顾性分析 1991年 1月～ 2 0 0 2年 3月间我院收治壶腹周围癌 4 9例的手术治疗情况。结果　 4 9例中 ,胰头癌2 6例 ,占 5 3 % ;壶腹癌 11例 ,占 2 2 .4 % ;胆管下端癌 7例 ,占 14 .2 % ;十二指肠乳头癌 5例 ,占 10 .2 %。4 5例行手术切除 ;未能切除的 4例采用胆囊十二指肠吻合术 ,胰头部用微波固化病灶。全组并发胰瘘 2例、腹腔内出血 1例、腹腔感染 1例、消化道出血 1例。术后死亡 2例 ,死于腹腔内出血、腹腔感染、多器官功能衰竭。结论　由于新的围手术期治疗和监护技术的进步 ,壶腹周围癌的手术死亡率和并发症发生率均有明显下降     

腹腔镜下行胰头十二指肠切除术的初步经验和体会(附4例报道)

目的总结腹腔镜胰头十二指肠切除术在壶腹周围癌中应用的初步经验和体会。方法回顾性分析中国医科大学附属盛京医院胰腺外科2016年7月至2016年9月期间连续实施腹腔镜胰头十二指肠切除术治疗4例壶腹周围癌患者的临床资料。结果本组2例患者行完全腹腔镜下胰头十二指肠切除术,2例行腹腔镜下切除、小切口开放辅助吻合。所有病例均为R0切除。4例患者均行胰肠导管对黏膜吻合术。手术时间为510~600 min,术中出血量为400~600 m L,术后住院时间为15~21 d,术后下床活动时间为6~7 d。术后3例发生A级胰瘘,均经冲洗引流自愈;1例无胰瘘。4例患者均无术后出血、排空障碍、腹腔感染及胆汁漏发生,也无围手术期死亡患者。术后病理诊断:胰头导管腺癌1例,胰头钩突囊腺癌1例,十二指肠乳头癌1例,胆总管下端癌1例。结论从本研究有限病例的初步结果显示,腹腔镜胰头十二指肠切除术是安全、可行的,这种手术的开展和推广可以减少患者围手术期的心肺并发症,更早排气、进食和下床活动,更好地耐受手术,但手术并发症不能因此而减少。     

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.     

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.     

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.     

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.     

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.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.