十二指肠损伤的诊断及治疗

目的提高十二指肠损伤早期确诊率。方法报道１６例十二指肠损伤的诊治体会及５例Ｃｏｇｂｉｌ改良憩室化手术再简化的手术治疗经验。结果十二指肠损伤的早期诊断和及时手术治疗是非常重要的。结论Ｃｏｇｂｉｌ改良手术再简化手术是治疗十二指肠损伤的一种操作简单,远期并发症少的术式     

结直肠吻合的预防性造口术——袢式横结肠造口与袢式回肠造口的比较

作为结直肠吻合口的预防性造口,袢式回肠造口与横结肠造口均可有效地转流粪便,减少吻合口漏所带来的危害,适用于具有高吻合口漏风险的低位、超低位直肠癌切除患者,特别是接受新辅助治疗者。两种造口各有利弊。本文总结了关于这两种造口的大部分对照研究,结果显示袢式横结肠造口术后的并发症率相对较高,主要包括造口脱垂、旁疝、伤口感染、还纳术后切口疝等。袢式回肠造口的主要缺点是造口高排便量、脱水以及术后肠梗阻风险。另一方面,由于部位等原因,袢式横结肠造口可以更为有效地进行结直肠减压,更适用于无法进行肠道准备如急诊手术等情况。通过手术技术的改进,或可有效地减少造口脱垂等并发症,充分发挥袢式横结肠造口的优势。     

肠造口的临床应用

肠造口是腹部外科急症临时性或根治性的永久性治疗措施。它既是挽救患者生命所需要,也可成为患者永久生活的一个保证。肠造口按肠管、造口部位及性质的不同,一般可分为小肠或结肠造口、腹部或会阴造口以及临时性或永久性造口,下面作一简要介绍。一、临时性肠道腹壁造口术1.临时性不完全转流性肠道腹壁造口术犤1,2犦:多用于结肠疾病,如急性结肠的梗阻、坏死和穿孔,创伤或战伤所引起的结肠损伤和破裂伴全腹膜炎及休克者,尤其是年老者。方法:急症手术进腹、吸尽腹腔内的粪便与脓液,将破孔缝合,然后把破孔近侧游离的肠段(也可将破孔或有肿瘤的肠…     

三孔法完全腹腔镜胃/空肠造瘘术

目的：总结三孔法完全腹腔镜胃/空肠造瘘术的初步经验。方法：回顾分析2007年10月至2009年11月采用三孔法行完全腹腔镜胃/空肠造瘘术放置永久性胃/空肠造瘘管10例的临床资料,其中晚期食管癌1例,晚期贲门癌2例,晚期胃癌7例,均完全或几乎不能经口进食,行三孔法完全腹腔镜胃造瘘术3例,三孔法完全腹腔镜空肠造瘘术7例。结果：本组手术均获成功,无中转开放,手术时间45~110min,平均60min,术中出血5~15ml,平均8.5ml,术后住院5~11d,平均7.2d。术后均无并发症发生,造瘘管均顺利开放并维持正常肠内营养。结论：三孔法完全腹腔镜胃/空肠造瘘术放置胃/空肠造瘘管具有患者创伤小、康复快、启用造瘘管早等特点,临床效果满意,值得推广。     

经环状软骨气管造口术（附200例报告）

传统的气管造口术都是经 2～ 4气管软骨环切开插管 ,不作高位切开是预防术后发生喉狭窄。我科 1995～ 1999年采用经环状软骨行气管造口术[1] 2 0 0例 ,疗效满意。现结合近期国内外文献经验 ,介绍如下。1　临床资料本组男 10 8例 ,女 92例。年龄最大 82岁 ,最小 12岁 ,平均 46岁。颅脑外伤 12 0例 ,脑出血 75例 ,肿瘤 2例 ,喉外伤 3例。因异物、分泌物、血液及舌根后坠等阻塞而呼吸困难急诊手术者 5 6例 ,仅有意识障碍无呼吸困难行预防性切开者 144例。手术方法 :病人仰卧 ,肩下略垫高 ,头略后仰 ,充分显露颈前区 ,术者于病人左侧 ,以左手扪…     

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结直肠切除术(proctocolectomy)指切除全部的结肠以及直肠或直肠黏膜，行末端回肠造口或回肠肛管吻合术。主要用于累及整个大肠而又需要手术处理的病变，如溃疡性结肠炎、大肠家族性息肉病、克罗恩病、多源发大肠癌、先天性巨结肠等。结直肠切除术后消化道重建有多种方式，如末端回肠造口术、可控性回肠造口术、回肠肛管直接吻合术以及回肠贮袋肛管吻合术等。     

经皮内镜引导下盲/结肠造口术治疗溃疡性结肠炎

目的总结经皮内镜引导下盲/结肠造口术(PEC)在治疗溃疡性结肠炎(UC)中的应用体会,探讨PEC的适应证、实施方法及并发症。方法回顾性分析了2009年12月以来2例应用PEC行顺行灌肠治疗UC的实施方法,观察治疗前后UC临床严重程度分级、内镜分级及病理组织学分级变化。结果 2例患者UC临床严重程度分级、内镜分级及病理组织学分级明显好转,无明显并发症。结论应用PEC行顺行灌肠治疗UC是安全、有效的。     

经皮内镜胃联合空肠造瘘在普通外科疾病中的应用(附12例报告)

目的:探讨经皮内镜胃造瘘(percutaneous endoscopic gastrostomy,PEG)联合经皮内镜空肠造瘘(percutaneous endoscopic jejunostomy,PEJ)用于治疗普通外科多种疾病的价值。方法:2003年10月至2008年6月我院为12例普通外科疾病患者行PEG联合PEJ治疗,其中术后胃瘫2例,胆汁回输4例,胰头癌致胃十二指肠不全梗阻6例。结果:12例PEG及PEJ均一次性完成,手术成功率100%。2例造瘘管周围感染,患者PEG/J管发挥作用后逐步停用原有鼻胃(肠)管,改静脉营养补液为肠内营养补液,患者病情明显好转,9例带管出院,3例病情恢复后拔除PEG/J管,瘘口愈合,起到了替代原有鼻胃(肠)管的治疗作用;患者带管期间原有的咽喉部不适等症状消失,满意度高于传统的经鼻胃(肠)管。结论:PEG/J管是建立胃(肠)腔与外界通道的一种非常微创、有效和安全的方法,PEG置管可替代普通外科中大部分较长期的经鼻置胃(肠)管和手术胃(肠)造瘘置管,值得推广。     

经皮肾镜与纤维胆道镜用于腹腔镜胆总管切开取石对比研究

目的探讨经皮肾镜(硬镜)和纤维胆道镜(软镜)联合腹腔镜处理胆总管结石的应用价值。方法回顾性分析本院2014年1月至2016年1月间接受腹腔镜胆总管切开取石术的47例患者临床资料。所有患者术前均行CT及彩超检查确诊为胆总管结石,按照术中使用的内镜不同分成软镜组(23例,直接置入纤维胆道镜)和硬镜组(24例,置入18~20号外鞘,再于鞘内置入经皮肾镜),统计分析两组患者在手术时间、术中出血量、术后出血、胆漏、结石残留等情况的差异。结果硬镜组均顺利完成手术,而软镜组则有3例术中需协同使用硬镜来取出结石,结石取出率差异无统计学意义(100.0%vs 87.0%,c2=3.344,P=0.067)。硬镜组和软镜组的手术时间差异有统计学意义[(124.2±20.4)min vs(152.8±29.0)min,t=-3.924,P0.05],术中出血量[(28.70±8.69)ml vs(26.67±8.17)ml,t=-0.825,P=0.414)]、术后出血(4.2%vs 0,c2=0.979,P=0.322)、术后胆漏(8.3%vs13.0%,c2=0.274,P=0.601)及结石残留率(0 vs 8.7%,c2=2.180,P=0.140)差异均无统计学意义。结论对于单纯胆总管结石患者,硬镜及鞘管在腹腔镜胆总管切开取石术中的应用可极大地减少取石、碎石时间,缩短手术时间,较软镜优势明显。     

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.