十二指肠第三、四段切除术四例

例 1　女 ,30岁。因胃溃疡施行胃大部切除、经结肠后Billroth Ⅱ式胃肠重建术 ,1周后出现上腹疼痛、呕吐、腹胀、腹肌紧张。腹部X线透视 :左上腹有液平面。再次手术探查。术中发现腹腔内约有 80 0ml含胆汁暗黑色液体 ,部分空肠经胃空肠吻合口后间隙疝入 ,压迫空肠输入襻致梗阻 ,十二指肠扩张显著 ,第三段扩张尤甚 ,呈囊袋状 ,且已发黑坏死并穿孔 ,十二指肠第二段 (降段 )血运良好 ,腹膜后也有较多与腹腔内相同的液体。诊断 :内疝、输入襻梗阻、十二指肠部分坏死穿孔。清除腹腔内及腹膜后液体 ,切除空肠输入襻及十二指肠第三、四段 ,封闭靠…     

肠系膜上动脉综合征的术式选择

目的　总结手术治疗肠系膜上动脉综合征的经验。方法　对近 10年手术治疗的 11例肠系膜上动脉综合征患者的病因、诊断、术前准备和手术方式进行回顾性分析。结果　 11例患者共施行手术 12次。行 Treitz韧带松解 1例 ,Billroth 式胃大部切除、十二指肠空肠侧侧吻合 3例 ,十二指肠空肠 Roux- Y吻合 4例 (其中 1例为胃空肠吻合术后再手术 ) ,十二指肠环形引流术 1例。全部病人随访均痊愈。结论　十二指肠空肠吻合术是治疗肠系膜上动脉综合征简单有效的手术方式     

肠系膜上动脉综合征21例术式的选择

目的　探讨肠系膜上动脉综合征的术式选择。方法　对 1 992年 1月至 2 0 0 2年 1月诊治的 2 1例肠系膜上动脉综合征患者的资料进行回顾性分析。结果　非手术治疗 3例 ,手术治疗 1 8例 ,均治愈出院。其中Treitz韧带切断松解、下移术 (Ⅰ型术式 ) 4例 ;Treitz韧带松解、下移术加十二指肠空肠侧侧吻合、空肠空肠端侧Roux en Y吻合术 (Ⅱ型术式 ) 9例 ;十二指肠横行部、空肠侧侧吻合术(Ⅲ型术式 ) 1例 ;胃大部分切除 胃空肠吻合术 (BillrothⅡ式 ,Ⅳ型术式 ) 2例 ;十二指肠空肠血管前移位吻合术 (Ⅴ型手术 ) 2例。其中 1例Ⅰ型术式、1例Ⅲ型术式经第 2次改行Ⅱ型术式后痊愈。结论　正确判断致病因素及选择合适的治疗方法和手术方式 ,才能获得满意效果。     

肠系膜上动脉压迫综合征20例报告

目的探讨肠系膜上动脉压迫综合征（superior mesenterie artery syndrome,SMAS）的术式选择。方法对我院2000年1月至2007年12月期间收治的行手术治疗的20例SMAS的临床资料进行回顾性分析。结果本组行Treitz韧带松解加十二指肠空肠侧侧吻合术9例,Treitz韧带松解加十二指肠空肠Roux-en-Y吻合术5例,均痊愈;行胃大部切除、胃空肠吻合术4例,均好转;单纯胃空肠吻合术2例,术后症状均仅有所改善,1例改行十二指肠空肠Roux-en-Y吻合术后痊愈,另1例非手术治疗1个月后治愈。结论SMAS的手术治疗效果以Treitz韧带松解加十二指肠空肠吻合术为最佳。     

胆囊十二指肠内瘘并发胆石性肠梗阻16例临床诊治分析

目的:探讨胆囊十二指肠内瘘合并胆石性肠梗阻的诊断及治疗方法。方法:回顾性分析2013年1月—2017年6月手术治疗16例胆囊十二指肠内瘘合并胆石性肠梗阻患者的临床资料。结果:16例患者中,8例患者术前明确诊断,8例患者于术中明确诊断;术前诊断合并胆囊结石胆囊炎7例,合并十二指肠溃疡、胃溃疡的5例。16例患者均行手术治疗,行小肠切开取石+胃大部切除术(Billroth Ⅱ式)+空肠Braun吻合术7例,行小肠切开取石+胃大部切除术(Billroth Ⅱ式)3例,行胃窦部切开取石+胃大部切除术(Billroth Ⅱ式)+空肠Braun吻合术2例,行小肠切开取石+胆囊切除+十二指肠瘘修补+十二指肠造瘘+空肠造瘘术4例。平均手术时间115min,平均住院时间8d,平均术后9d开始进食流质。术后肺部感染4例,十二指肠漏2例,术后吻合口出血1例,切口感染3例。16例患者均治愈出院。结论:术前CT及B超等辅助检查对于该病的诊断十分重要,对于胆囊严重炎症粘连者,特别是合并十二指肠溃疡、胃溃疡者行胃大部切除术(Billroth Ⅱ式)+空肠Braun吻合术效果良好,对于胆囊炎症较轻者,可考虑行胆囊切除+十二指肠瘘修补+空肠造瘘术,十二指肠球部结石梗阻患者可经胃窦切开取石。     

肠系膜上动脉压迫综合征的外科治疗

目的 对肠系膜上动脉压迫综合征(superior mesenteric artery compressing syndrome,SMACS)的诊断及术式选择进行评价。方法 对河南省人民医院2000年1月至2010年12月期间收治的28例SMACS患者的临床资料进行回顾性分析。结果 本组病例均行X线钡餐检查,有23例呈典型的十二指肠水平段与升段交界处纵行受压迫征象（笔杆征）。手术治疗28例,其中包括Treitz韧带切断松解术4例,单纯胃空肠吻合术2例,Treitz韧带松解加十二指肠空肠Roux-en-Y吻合术11例,胃大部切除、胃空肠吻合术（BillrothⅡ式）7例及肠系膜上血管前十二指肠空肠吻合术4例。全部病例均治愈出院。结论 SMACS主要的确诊手段为X线钡餐造影。手术治疗效果以Treitz韧带松解加十二指肠空肠Roux-en-Y吻合术为最佳。     

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1　病历简介例 1.女 ,3 0岁。因胃溃疡行了胃大部切除、经结肠后Billroth Ⅱ式胃肠重建术。术后第 4天胃肠功能恢复 ,拔除胃管开始进流质食物 ,第 7天拆除切口皮肤缝线。术后第8天下午病人出现上腹疼痛 ,检查上腹部压痛、软。对症处理 ,并再禁饮食。第 9天出现呕吐 ,安放胃肠减压管 ,继续观察。第 10天下午腹痛加重 ,腹部X线透视见左上腹有液平面 ,当晚行二次手术。术中见部分空肠经胃空肠吻合口后间隙疝入 ,压迫空肠输入襻使之梗阻 ,十二指肠第 3段扩张呈囊袋状 ,且已发黑坏死并穿孔 ,十二指肠第 2段血运良好。诊断 :内疝、输入襻梗阻、十…     

肠系膜上动脉压迫综合征的诊断及术式选择评价

目的对肠系膜上动脉压迫综合征（superior mesenteric artery compressing syndrome,SMACS）的诊断及术式选择进行评价。方法对我院1999年1月至2006年12月期间收治的38例SMACS患者的临床资料进行回顾性分析。结果本组病例均行X线钡餐检查,有32例呈典型的十二指肠水平段与升段交界处纵行受压迫征象（笔杆征）,21例钡剂在胃和十二指肠内形成明显的反复交流的“钟摆样”运动。行非手术治疗9例,手术治疗29例。其中手术包括Treitz韧带切断松解术4例,单纯胃空肠吻合术2例,Treitz韧带松解加十二指肠空肠Roux-en-Y吻合术7例,Treitz韧带松解加十二指肠空肠侧侧吻合术10例,胃大部切除、胃空肠吻合术（BillrothⅡ式）4例及肠系膜上血管前十二指肠空肠吻合术2例。全部病例均治愈出院。结论SMACS的诊断除应具有上腹胀痛、呕吐等典型症状外,主要的确诊手段为X线钡餐造影。治疗上首先采用保守治疗,无效者再行手术治疗。应正确判断致病因素,选择合适的手术方式,才能获得满意效果。     

十二指肠憩室手术疗效的Meta分析

目的 评价十二指肠憩室各种术式的疗效.方法 检索<中国期刊全文数据库(CJFD)>2000年1月至2006年8月国内公开发行的关于十二指肠憩室的文章,对各种术式术后症状缓解率、并发症发生率等数据进行Meta分析.各种术式疗效之间的差异采用χ~2检验分析.结果 在症状缓解率方面,Billroth Ⅱ式胃大部切除术、胃空肠Roux-en-Y吻合术等胃肠转流术式与憩室切除术、憩室内翻缝合术、Oddi括约肌切开成形术比较差异有统计学意义(χ~2=21.269,4.285,12.914,19.266,3.938,P<0.05);在并发症发生率方面,Billroth Ⅱ式胃大部切除术、胃空肠Roux-en-Y吻合术与憩室切除术、憩室内翻缝合术比较差异有统计学意义(χ~2=4.164,9.166,7.926,4.659,4.858,P<0.05).结论 对于症状明显并经长期内科治疗无效的十二指肠憩室炎及其并发症,经不同的术式均可获得满意的疗效,尤以Billroth Ⅱ式胃大部切除术或胃空肠Roux-en-Y吻合的憩室旷置术安全,并发症少,预后良好.     

直线型切割吻合器在BillrothⅡ式胃大部切除中的应用体会

我院自1995年以来应用直线型切割吻合器行远端胃大部切除术后胃空肠侧侧吻合47例,疗效满意,现报告如下。临床资料本组47例中,男31例,女16例。年龄23～78岁,平均46.3岁。胃窦癌行远端胃大部切除26例,壶腹周围癌行胰十二指肠切除术胃空肠吻合21例。吻合器类型:所用吻合器为TCL55～77(55～77mm)型直线切割吻合器(均为强生公司产品)。吻合方法:(1)胃窦癌远端胃大部切除术后吻合:远端胃大部切除后,用闭合器(TL90,强生公司产品)或手缝闭合残胃断端。将残胃的大弯侧胃结肠韧带和脾胃韧带向上游离8cm左右,以便空肠在胃后壁与其进行侧侧吻合。距屈…     

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.     

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.     

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.     

Development of Selective Low-Density Lipoprotein (LDL) Apheresis System: Immobilized Polyanion as LDL-Specific Adsorption for LDL Apheresis System

Abstract: Low-density lipoprotein (LDL) is widely recognized as one of the major risk factors for developing coronary heart diseases. Despite intensive development of LDL-lowering drugs, there still exist those patients with refractory hyperlipidemia whose plasma LDL levels are not sufficiently lowered by drugs. LDL apheresis, direct removal of plasma LDL from circulating blood, is thought to be the most promising treatment for such refractory patients. Various techniques, such as the use of an im-munoadsorbent utilizing an anti-LDL antibody, have been used in an attempt to achieve the selective removal of LDL. However, none were widely used because of complications, poor selectivity, and so forth. To establish a safe and effective LDL apheresis system, we chose a synthetic affinity adsorbent as the LDL-removing device. Synthetic polyanion compounds were used as the affinity ligands for LDL adsorbent to simulate the anion-rich sequence of LDL binding sites in the human LDL receptor. Among various polyanion compounds, those polyanions with sulfate or sulfonate groups and hydrophilic backbone were found to have strong affinity for LDL. In contrast, polyanions with carboxyl groups showed poor affinity. Dextran sulfate (DS) was selected as the affinity ligand of LDL adsorbent for its high affinity and low toxicity. The influence of its charge density and molecular weight on its affinity for LDL was suitable. The affinity rapidly increased as the charge density increased, then, reached a constant value. Little affinity was found for either the DS monomer (glucose sulfate) or DS with a molecular weight higher than 10⁴ daltons whereas DS with molecular weights in the midrange showed strong affinity. DS with a midrange molecular weight was immobilized on cellulose hard gel to give LDL adsorbent clinical application. The adsorbent demonstrated an excellent selectivity for LDL and very low density lipoprotein (VLDL) in vitro. Adsorption of high-density lipoprotein and major plasma proteins was almost negligible. Additional study of the LDL-binding mechanism revealed that DS directly interacts with positively charged sites on LDL, which demonstrates that the nature of the interaction is the same as that of LDL receptor. An LDL adsorption column (Liposorber) packed with an LDL adsorbent and polysulfone hollow-fiber plasma separator (Sulflux) was developed as an efficient LDL apheresis system. Clinical investigation proved that this system is capable of intensively lowering the plasma LDL level without affecting major plasma components.     

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.     

Artificial organs 2010: a year in review

In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.     

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.     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.