腹腔镜下再次胆道手术83例报告

目的探讨腹腔镜再次胆道手术的手术方法。方法回顾性分析从1995年8月至2011年6月经腹腔镜胆总管探查(LCBDE),腹腔镜球囊导管扩张内涵管引流术(LPBD)对胆道术后胆总管复发性结石或残留结石的83例患者腹腔镜再次胆道手术,治疗胆道术后复发或残留结石和胆道狭窄。结果 83例腹腔镜再次胆道手术成功率:开腹胆囊切除术后93.1%(27/29);开腹胆囊切除及胆管探查术后82.4%(14/17);开腹胆囊造瘘术后100%(9/9);开腹胆囊造瘘及胆总管T管引流术后100%(11/11);腹腔镜胆囊切除术后100%(12/12)和腹腔镜胆总管探查术术后100%(5/5)。腹腔镜再次手术获总成功率78例(94.0%),5例中转开腹。术后无并发症发生,无死亡病例。腹腔镜手术时间60～190min,平均120min。结论选择合适患者,腹腔镜再次胆道手术治疗胆管结石和胆管狭窄可以有效预防复发,具创伤小、安全、可行。     

腹腔镜胆囊切除术中胆囊-结肠瘘的诊断与治疗

目的探讨腹腔镜胆囊切除术中胆囊-结肠瘘的诊断与治疗的可靠性和安全性。方法回顾性分析2002年1月至2015年12月期间甘肃省人民医院普外科腹腔镜胆囊切除术中通过常规胆道造影确诊的胆囊-结肠瘘患者的临床资料。共计11 472例腹腔镜胆囊切除术患者,通过术中胆道造影确诊胆囊-结肠瘘112例,占0.98%。其中男33例,女79例;年龄(67.4±12.6)岁(58~84岁)。结果腹腔镜胆囊切除术中的胆囊-结肠瘘均通过术中胆道造影确诊,其中行腹腔镜胆囊切除加结肠修补105例,结肠造瘘7例,无手术并发症发生;术后随访70例(结肠修补65例,结肠造瘘5例),随访时间(16.4±5.3)个月(6~27个月),无远期并发症发生。结论胆囊-结肠瘘无特异性症状,术前无特殊诊断方式,术中胆道造影是唯一的客观诊断方法。在掌握娴熟的腹腔镜外科技术条件下行胆囊切除及结肠瘘口修补/造瘘术安全、可靠。     

胆囊结石病所致胆道内瘘的诊断与治疗

目的 探讨胆囊结石病引起胆道内瘘的原因，提高其诊断和治疗水平。方法 收集我院1990-1999年收治的胆道内瘘患者46例，并对其病因，诊断与治疗进行分析。结果 胆囊十二指肠瘘18例（39.1%)，胆囊结肠瘘8例（17.4%)。胆囊与胃，空肠内瘘各1例（4.3%)；胆囊胆管瘘18例（39.1%)。术后出现并发症4例（8.7%)。死亡1例(2.2%)，治愈率为97.8%。结论 重视本病的临床表现及术前，术中检查，选择恰当手术方式，可减少死亡与并发症的发生。     

老年性胆道疾患的围手术期处理体会

目的 总结老年胆道围手术期处理效果。方法 对1988～1998年老年胆道手术130例,其中胆囊切除术34例,胆囊造瘘术21例,胆总管引流及胆囊造瘘术23例,胆囊切除及胆总管切开引流39例,胆总管切开取石及引流术11例,2例胆囊切除及胆总管、十二指肠吻合术,作回顾性分析。结果 急诊手术死亡率7.5％,择期手术死亡率2.5％,术后并发症发生率15.4％。     

老年人胆道疾病的外科治疗

目的　探讨 6 0岁以上老年人胆道疾病的外科处理方法及其效果。方法　回顾性总结了 1992年 1月～ 2 0 0 0年 1月间12 7例老年胆道疾病的外科治疗情况。结果　本组胆囊切除和 /或胆总管探查术 78例 ,胆囊造瘘术 12例 ,各类型胆肠吻合术 2 7例 ,Oddis括约肌切开成形术 3例 ,PTCD4例 ,剖腹探查、组织活检术 3例 ,本组中联合左肝外叶切除 11例。术后总病死率 5 .5 % ,急诊手术病死率 12 .8% ,择期手术的占 2 .3% ,x2 =3.92 37,P<0 .0 5。结论　对老年胆道疾病患者 ,尤其存在合并症者 ,应积极作好围手术期处理 ,在适当的时机选择适合老年病人特点的手术方式 ,以期最大限度地减少术后并发症 ,降低病死率。     

术中胆囊造影在保胆手术中的应用体会

目的:探讨经胆囊行胆道造影在腹腔镜保胆手术中的应用效果及临床价值。方法:回顾分析2010年1月至2013年5月于98例保胆手术中经胆囊行胆道造影的临床资料。结果:98例患者中34例胆囊、肝内胆管、胆总管及十二指肠均显影,20例仅胆囊显影,44例胆囊、肝内胆管、胆总管上段显影。34例胆道均显影的患者一次性手术成功;14例行胆囊切除术;3例先行胆囊造瘘后二次手术行胆囊切除术;3例行胆囊造瘘术,二期经瘘道胆道镜探查成功保胆,行保胆取石术;44例行胆总管切开探查术。其中81例成功保胆。术后无并发症发生。结论:保胆手术中经胆囊行胆道造影既可了解胆道系统情况,又可为术中是否行胆总管探查提供依据,是较好的检查方法。     

12例胆内瘘诊治体会

目的总结胆内瘘的临床诊治体会。方法回顾性分析12例胆内瘘的临床资料。6例(50.0%)患者术前获确诊,其中经T管造影确诊1例,胃镜、钡餐各确诊1例,胃镜和钡餐共同确诊1例,内镜逆行胆胰管造影(endoscopic retrograde cholangiopancreatography,ERCP)确诊2例;6例(50.0%)患者为术中发现。5例行胆道探查+T管引流+胆囊切除+内瘘修补术;1例行再次胆道探查+T管引流+内瘘修补术;1例十二指肠球部溃疡并穿孔、胆囊十二指肠瘘者,行BillrothⅡ式胃大部切除术+十二指肠旷置术,瘘口未予处理;1例胆石性肠梗阻患者行胆囊造瘘+十二指肠内瘘修补术+回肠部分切开取石术。另4例行保守治疗。结果手术治疗的8例均治愈出院,保守治疗的4例亦获好转。结论 B超、胃镜、钡餐、ERCP及胆道造影有助于胆内瘘的诊断;选择合适的手术时机和正确的处理方法,有利于提高胆内瘘的治疗水平。     

婴儿阻塞性黄疸的腹腔镜早期干预与治疗

目的 探讨腹腔镜胆道探查对婴儿阻塞性黄疸的诊断和治疗价值.方法 对56例经内科保守治疗2周血清胆红素水平无明显下降的阻塞性黄疸婴儿进行胆道探查及胆道造影,并对诊断明确的非先天性胆道闭锁患儿予以胆道冲洗.结果 本组56例婴儿经腹腔镜胆道探查及胆道造影后均明确诊断,其中浓缩胆栓综合征12例(21%),胆管发育不良4例(7%),胆道闭锁40例(72%).16例非先天性胆道闭锁患儿经胆囊造瘘、胆道冲洗后病情好转,黄疸消退,随访6～42个月,均恢复良好无复发.结论 利用腹腔镜早期干预阻塞性黄疸患儿可以对疾病进行早期的诊断和治疗,具有较高的临床实用价值.对浓缩胆栓综合征及先天性胆管发育不良患儿,可以在镜下造影明确诊断后行胆囊造瘘及胆道冲洗,以减轻胆汁淤积对肝脏的进一步损害;对胆道闭锁患儿可以争取到早期手术的时机.     

腹腔镜胆囊造瘘术联合术后胆道镜取石在高龄急危重症胆囊结石患者的临床观察

探讨腹腔镜胆囊造瘘术联合术后胆道镜取石对高龄急危重症胆囊结石患者的疗效。分析山东省立三院以腹腔镜胆囊造瘘术结合术后胆道镜取石治疗的高龄急危重症胆囊结石并胆囊炎患者33例的临床资料。33例患者全部为腹腔镜胆囊切除困难、中转为腹腔镜胆囊造瘘术者,术后1月患者行胆道镜检查,7例患者结石消失;24例患者取净胆囊内结石,拔除造瘘管;2例患者因胆囊颈部结石嵌顿,无法取净结石,给予二期胆囊切除,术后恢复良好。对于腹腔镜胆囊切除困难的急危重症胆囊结石患者,腹腔镜胆囊造瘘术可迅速缓解患者危急症状,术后通过胆道镜取净胆囊内结石,保留胆囊部分功能;减少手术并发症,更安全、有效,值得推广。     

腹腔镜手术治疗急性化脓性胆囊炎（附156例报告）

目的探讨腹腔镜手术治疗急性化脓性胆囊炎的可行性、安全性。方法对2005年1月～2008年5月156例急性化脓性胆囊炎行腹腔镜手术的临床资料进行回顾性分析。常规四孔法腹腔镜胆囊切除术,对胆囊三角解剖不清者行胆囊造瘘或胆囊大部分切除术。结果156例均行腹腔镜手术,其中139例（89.1%）顺利完成腹腔镜胆囊切除术,6例（3.8%）行胆囊造瘘,11例（7.1%）行胆囊大部分切除术,无一例中转开腹。手术时间35～180min,平均75min。13例直接胆红素升高和（或）胆总管扩张术中胆道造影示9例胆总管结石,腹腔镜下切开取石,T管引流,术后2个月造影后拔管。156例术后随访3～6个月,无黄疸、腹痛、发热等并发症,无胆总管残留结石。结论腹腔镜手术治疗急性化脓性胆囊炎是一种安全、可行的治疗方法。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

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.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

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.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.