Acute Cholecystitis and Severe Ischemic Cardiac Disease: Is Laparoscopy Indicated?

BACKGROUND AND OBJECTIVES: Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication. METHODS: We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined. RESULTS: The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).     

异氟醚预处理脑保护作用的剂量-效应关系

目的　研究异氟醚预处理脑保护作用的剂量效应关系 .方法　 4 0只雄性 SD大鼠 ,随机分为 4组 :对照组 ,Iso1,Iso2和 Iso3组 (n=10 ) .对照组大鼠每日吸 4 L· min- 1 (970m L· L- 1 O2 ) O2 1h,连续 5 d.Iso1,Iso2和 Iso3组大鼠分别接受浓度为 7.5 ,15 .0和 2 2 .5 m L·L- 1 的异氟醚预处理 (异氟醚和 4 L· min- 1 O2 ) ,每日 1h,连续 5 d.最后 1次处理结束 2 4 h后 ,用右侧颈内动脉尼龙线线栓法制作大脑中动脉阻闭 (middle cerebral artery occlusion,MCAO)模型 .异氟醚预处理效果根据再灌注 2 4 h时的神经损害评分及脑梗死容积判定 .结果　 Iso2和 Iso3组大鼠神经功能障碍及脑梗死容积均与对照组及 Iso1组相比差异显著 (P<0 .0 5 ) .Iso3组大鼠神经功能障碍及脑梗死容积与 Iso2组相比差异显著 (P<0 .0 5 ) .结论　异氟醚预处理需达到一定浓度才能诱导脑缺血耐受 ,并存在一定的剂量效应关系     

阿片受体在异氟醚延迟预处理减轻兔心肌缺血再灌注损伤中的作用

Objective To investigate the role of opioid receptors in the protective effects of isoflurane-induced delayed preconditioning against myocardial ischemia-reperfusion (I/R) injury in rabbits. Methods Forty male New Zealand white rabbits weighing 2.0-2.5 kg were randomly assigned into 4 groups ( n = 10 each) : group I sham operation (S); group II I/R; group Ⅲ isoflurane + I/R (Iso) and group IV Iso + naloxone + I/R (Nal). Myocardial I/R was induced by 40 min occlusion of left anterior descending branch (LAD) of coronary artery followed by 120 min reperfusion. In group Ⅲ (Iso) 2% isoflurane in 100% O2 was inhaled for 2 h and I/R was produced 24 h later. In group IV (Nal) naloxone 6 mg/kg was given iv 10 min before 2 h of 2% isoflurane inhalation and I/R was produced 24 h later. At the end of 120 min reperfusion, infarct size (IS) and area at risk (AAR) were determined by Evan's blue and TTC staining. Myocardial ultrastructure was examined by electron microscopy. The phosphorylated p38MAPK protein expression in myocardium was determined by Western blot. Results The IS was significantly smaller in group Iso ( Ⅲ ) ( 19.7% ± 2.8%) than in I/R group ( II ) (37.8% ±1.7%) (P<0.05). The phosphorylated p38MAPK protein expression in myocardium was significantly lower in group Iso than in group I/R. Microscopic examination showed less myocardial damage in Iso group than in group I/R. The protective effects of delayed preconditioning by isoflurane was prevented by naloxone pretreatment. ConclusionOpioid receptors may be involved in the protective effects of delayed preconditioning by isoflurane against myocardial I/R injury.     

七氟醚预处理对体外循环冠状动脉旁路移植术病人围术期心肌的保护作用

目的探讨七氟醚预处理对体外循环(CPB)下冠状动脉旁路移植术(CABG)病人心肌的保护作用。方法择期CPB下CABG病人40例,ASAⅡ级或Ⅲ级,随机分为2组(n=20):七氟醚组(S组)或异丙酚组(P组)。麻醉维持:P组靶控输注异丙酚,血浆靶浓度2～3μg/L,静脉输注芬太尼2～3μg·kg~(-1)·h~(-1);S组夹闭主动脉前,吸入0.5%～2%七氟醚,静脉输注芬太尼2～3μg·kg~(-1)·h~(-1),夹闭主动脉后靶控输注异丙酚,血浆靶浓度2～3μg/L,静脉输注芬太尼2～3μg·kg~(-1)·h~(-1)。于切皮前即刻、CPB前即刻、CPB后即刻、回ICU后即刻、6、12h记录心率(HR)、平均动脉压(MAP)、肺动脉楔压(PCWP)、中心静脉压(CVP)、心脏指数(CI)、体循环血管阻力指数(SVRI)。于麻醉诱导前、回ICU后即刻、6、12、24h采集静脉血,测定血清心肌肌钙蛋白I(cTnI)浓度。记录术后不良事件的发生情况。结果2组各时点MAP、PCWP、CVP、HR和SVRI比较差异无统计学意义(P>0.05);与切皮前即刻和P组比较,S组回ICU后各时点CI升高(P<0.05)。与P组比较,S组回ICU后各时点cTnI浓度降低(P<0.05)。2组病人术后均无死亡;2组心肌梗塞、房颤和心肌缺血的发生率差异无统计学意义(P>0.05);S组cTnI浓度>2ng/ml的发生率低于P组(P<0.05)。结论七氟醚预处理对体外循环下冠状动脉旁路移植术病人围术期心肌具有一定的保护作用。     

缺血性股骨头坏死患者血清透明质酸及层粘连蛋白的研究

为探讨细胞外间质主要成分透明质酸（ＨＡ）与层粘连蛋白（ＬＮ）在缺血性股骨头坏死（ＩＮＦＨ）中的生理病理过程及临床价值，采用放射免疫分析法对４５例不同病因的ＩＮＦＨ患者进行了血清ＨＡ与ＬＮ的定量分析，并与３０例正常人对照。结果显示，ＩＮＦＨ患者血清ＨＡ含量极显著地高于对照组（ｔ＝３－２９；Ｐ＜０－０１）。尤以激素性ＩＮＦＮ增高最为显著（ｔ＝３－６２；Ｐ＜０－０１）。ＩＮＦＨ患者ＬＮ含量亦明显高于对照组（ｔ＝２－８４；Ｐ＜０－０１）。同时，ＨＡ与ＬＮ含量增高与病程发展密切相关。故定量检测ＨＡ与ＬＮ可作为ＩＮＦＨ早期诊断及判断预后的良好指标     

神经元保护蛋白TAT-Bcl-XL的体外高效表达及其功能的初步研究

目的：在原核表达系统中表达对凋亡神经元具有保护作用的重要蛋白Bcl-XL与蛋白质转导序列（PTD）的融合蛋白，并检测重组蛋白对重金属离子所诱导的细胞凋亡的保护作用。方法：通过RT-PCR的方法，用Bcl-XL特异引物从乳腺癌细胞系MCF-7细胞的总RNA中扩增出Bcl-XL基因，构建相应的原核表达载体，体外表达的TAT-Bcl-XL融合蛋白经镍亲和层析介质纯化后，通过免疫荧光方法检测其转导293T细胞的能力；并用流式细胞仪检测融合蛋白抑制细胞凋亡的能力。结果：经RT-PCR从MCF-7细胞总RNA中得到相应的TAT-Bcl-XL基因片段，并将其克隆入pCRT7/CT-TOPO载体中，重组质粒pTBTOPO转化大肠杆菌后，在SDS-PAGE和Western blot的结果中出现了与预期分子量相同的蛋白条带和阳性信号，纯化的TAT-Bcl-XL重组蛋白经免疫荧光检测，主要分布于细胞的细胞质中。流式细胞仪的检测结果显示融合表达蛋白可以有效地抑制Zn2＋离子所诱导的细胞凋亡，使细胞的存活率提高40%。结论：TAT-Bcl-XL融合蛋白在大肠杆菌中获得高效表达，初步的功能性检测表明融合蛋白具有抑制细胞凋亡的功能。     

缺血预适应对大鼠心肌细胞凋亡及bcl-2、bax蛋白表达的影响

目的：探讨缺血预适应对大鼠心肌细胞凋亡及bcl-2、bax蛋白表达的影响。方法：以DNA电泳和TUNEL分析检测大鼠心肌组织的细胞凋亡情况，免疫组织化学方法检测bcl-2、bax蛋白的表达。结果：缺血再灌注组缺血区心肌DNA电泳呈现典型的DNA梯形，而缺血预适应组和假手术对照组未见梯形。缺血预适应组心肌细胞凋亡指数显著低于缺血再灌注组（P<0.01）。Bcl-2在各组均无阳性表达，bax在各组表达无显著差异（P>0.05）。结论：缺血预适应显著减少了缺血再灌注诱导的心肌细胞凋亡程度。     

Ischaemic episodes of less than 5 minutes produce preconditioning but not stunning in the isolated rat heart

The aim of the present study was to examine whether ischaemic episodes of less than 5 min could induce preconditioning or stunning in the isolated rat heart. Hearts were subjected to total global ischaemia of 1, 2 and 4 min followed by 10 min of reperfusion before an 18-min main ischaemic period and 30 min of reperfusion. The effects on physiology, purine metabolism and anaerobic glycolysis were compared with a control group subjected to the main ischaemia only. The brief ischaemic episodes did not produce stunning based on the recovery of left ventricular developed pressure (LVDP) and heart rate (HR) product during the first reperfusion. Preconditioning of 11–14% increased recovery of LVDP x HR during the second reperfusion was observed in the 1- and 4-min group. In the 2-min group a low repayment of flow debt during the first reperfusion was associated with a slightly reduced recovery of LVDP x HR compared to the other preconditioned groups during the second reperfusion. Only in the 4-min group was preconditioning associated with fewer breakdown products of the purine nucleotide pool (adenosine) and anaerobic glycolysis (lactate) in both tissue and effluate after the main ischaemia. Preconditioning (reflected in recovery of function) could be produced with ischaemic episodes of less than 5 min that did not produce stunning. Thus, stunning is probably not the primary cause of preconditioning.     

心率变异性在反映心脏自主神经损伤和重构中的应用

缺血预适应和急性心肌梗死恢复期都会出现心脏自主神经的变化,心率变异性（HRV）是无创测量心自主神经活动的重要方法.研究自主神经的变化能为疾病机理和临床用药研究提供理论基础,所以监测预适应和心梗后的HRV有着重要意义.本文综述了预适应和心梗恢复期在HRV上的体现,并将HRV的变化与生理生化证据相联系,分析了缺血预适应对自主神经的保护作用和心梗后用HRV检测自主神经恢复的可行性.同时还对心率变异性今后的研究方向做了展望.     

缺血后适应对大鼠脑缺血/再灌注损伤的影响

目的：探讨缺血后适应对大鼠脑缺血/再灌注损伤的影响。方法:应用线栓法制作大鼠脑缺血/再灌注损伤模型；21只雄性SD大鼠随机分为缺血/再灌注组、夹闭单侧颈总动脉后处理组和夹闭双侧颈总动脉后处理组，每组7只。再灌注48 h，测定脑梗死体积；拔栓后1 h及处死大鼠前进行神经功能测定；梗死即刻、梗死后10 min、术中1 h、拔栓后即刻、每次夹/松颈总动脉时、干预后30 min等15个时点监测脑血流。结果:夹闭单侧、双侧颈总动脉后处理组大鼠脑组织梗死体积与缺血/再灌注组相比明显减小，有显著差异；3组脑血流各个时点方差分析差异无显著，但是夹闭双侧颈总动脉后处理组干预30 min后脑血流百分比较缺血/再灌注组、夹闭单侧颈总动脉后处理组降低9％。手术后1 h 3组神经功能评分P<0.05，差异显著，夹闭单侧、双侧颈总动脉后处理组神经功能缺损均比缺血/再灌注组减轻。结论:缺血后适应能够明显减小梗塞体积，改善大鼠术后1h神经功能评分，可能与缺血后适应调节早期再灌注时血流动力学状态有关。