输尿管镜下钬激光碎石治疗输尿管上段结石129例体会

目的探讨输尿管镜下钬激光碎石术治疗输尿管上段结石疗效。方法回顾性分析输尿管镜下钬激光碎石术治疗输尿管上段结石129例患者的临床资料。结果术中完全碎石120例,术中结石移入肾盂5例,留置双J管后行体外冲击波碎石治疗。4例输尿管严重扭曲致进镜困难,留置双J管后行ESWL治疗。结论输尿管上段结石采用输尿管镜下钬激光碎石疗效肯定,术前严格选择适应证、术中熟练操作、灌注水流大小的调节、患者体位的调整及扭曲输尿管的处理,是手术成功的关键。     

输尿管镜下钬激光碎石术失败的原因与处理

目的探讨导致输尿管镜下钬激光碎石术治疗输尿管结石失败的常见原因与处理。方法回顾分析用输尿管镜钬激光碎石治疗输尿管结石手术失败的68例临床资料,对失败的原因及处理方法进行分析。结果输尿管狭窄或扭曲导致无法见到结石20例,结石部分或全部上移进入肾盂肾盏41例,输尿管穿孔7例。结论输尿管狭窄或扭曲、术中结石上移、输尿管穿孔是输尿管镜碎石术失败的主要原因。熟练的技术操作,严格掌握适应证,合适的术中处理是降低输尿管镜技术失败的关键。     

46例输尿管软镜联合钬激光碎石治疗上尿路结石失败原因分析

目的 分析输尿管软镜钬激光碎石术治疗上尿路结石手术失败的原因.方法 回顾本院2014年10月至2016年3月施行的472例软尿管软镜钬激光碎石术治疗上尿路结石病例,筛选46例手术失败病例,记录手术失败的原因,并进行分析.结果 手术失败的原因包括输尿管狭窄或扭曲因素19例(41.3％);肾盂输尿管与肾下盏漏斗部夹角过小11例(23.9％);未找到肾盏憩室结石开口4例(8.7％);肾内感染8例(17.4％);设备有关因素2例(4.3％);操作因素至输尿管损伤2例(4.3％).结论 术前留置1～2周双J管,充分抗感染治疗,常规行肾脏CT及IVU检查,术中留置安全导丝,操作轻柔,必要时经皮肾镜取石术是输尿管软镜钬激光碎石术处理上尿路结石成功的关键.     

输尿管镜下碎石术失败的原因与处理

目的:探讨导致输尿管镜下碎石术失败的常见原因与结果。方法:对21例应用输尿管镜下双频双脉冲激光或气压弹道碎石术治疗输尿管结石失败的病例进行分析。结果:上段结石整体或大于6 mm的结石碎块移入肾盂肾盏15例,其中6例行微创经皮肾穿刺肾镜下激光碎石治愈,9例留置双J管后经ESWL治疗痊愈。中段结石远端输尿管N形扭曲导致无法窥见结石4例,下段结石合并输尿管炎性息肉形成及狭窄导致无法窥见结石2例;该6例均改开放手术切开取石治愈。结论:输尿管镜下激光碎石术或气压弹道碎石术中,操作者熟练的操作,灵活地应用各种辅件,可以提高手术成功率,尤其是输尿管上段结石的单次治疗排空率。     

输尿管镜气压弹道碎石治疗输尿管上段结石临床体会

目的探讨输尿管镜气压弹道碎石术治疗输尿管上段结石疗效。方法对60例应用输尿管镜下气压弹道碎石术治疗输尿管上段结石回顾性分析。结果 46例患者术中完全碎石,12例患者术中结石移入肾盂,均留置双J管后行体外冲击波碎石(ESWL)治疗。2例输尿管扭曲或狭窄致进镜困难,无法窥见结石,其中1例转开放手术,1例置双J管后ESWL治疗。结论输尿管上段结石采用输尿管镜气压弹道碎石以及术后结合ESWL疗效肯定,但术中操作者的熟练操作、冲洗速度的调整、术前合适病例的选择是手术成功的关键。     

输尿管结石ESWL失败改腔内钬激光碎石术的疗效观察

目的 探讨输尿管结石ESWL失败后采用腔内钬激光碎石术的临床疗效。方法 自2001年10月至2002年8月，对28例输尿管结石(ESWL失败)行输尿管镜下钬激光碎石术。结果 26例经输尿管镜下钬激光碎石术治愈，治愈率92．8％(26／28)；1例结石上移，辅以ESWL治愈；1例因输尿管纤维性扭曲改开放手术。结论 输尿管镜下钬激光碎石术安全、有效、方便，可以作为输尿管结石的首选治疗。     

钬激光治疗ESWL失败的输尿管上段结石78例分析

目的探讨输尿管镜钬激光碎石术治疗体外冲击波碎石（extracorporeal shockwave lithotripsy,ESWL）失败的输尿管上段结石的临床效果。方法回顾性分析应用输尿管镜钬激光碎石术治疗ESWL失败的输尿管上段结石78例患者资料。结果输尿管上段结石并发炎性息肉者67例（86%）,碎石同时钬激光消融息肉。有输尿管扭曲、狭窄者16例（21%）。一次碎石成功63例,成功率81%。1周内结石排净46例,其余17例4周内结石排净。无输尿管穿孔、撕脱等严重并发症。11例结石冲回肾盂,经EWSL或经皮肾镜钬激光碎石术成功。4例置镜失败,行开放手术治愈。结论输尿管镜钬激光碎石安全有效,可作为ESWL治疗失败的输尿管上段结石首选治疗方法。     

输尿管软镜激光碎石术治疗肾结石338例报告

目的评价输尿管软镜结合钬激光和FREDDY激光处理不同部位肾结石的有效性,评价影响输尿管软镜碎石成功率的影响因素和手术技巧。方法回顾性分析2002年5月～2007年5月338例输尿管软镜激光碎石术。结石最大直径均〈20mm。288例结石位于上盏、中盏或肾盂内,37例位于下盏,13例位于多个肾盏内。术前均行泌尿系平片（KUB）＋静脉尿路造影（IVU）。放置Terumo导丝后,首先使用F8/9.8Wolf输尿管硬镜探查患侧输尿管。顺利进镜的患者放置输尿管软镜鞘并改用OlympusP3F6.9输尿管软镜。若输尿管硬镜无法顺利进镜,则在放置导丝后留置双J管,2周后行二期输尿管软镜碎石术。使用WOMU-100FREDDY激光或Lumenis钬激光碎石。术后常规留置F7双J管2周。术后第1天拔除导尿管,术后常规静脉给予广谱抗生素2天。2周后拔除双J管,4周后复查KUB或双肾CT平扫,评估结石排净率。残留结石≥4mm为有意义的结石残留。结果一次进镜成功率91.7%（310/338）,余28例进镜失败者在成功留置导丝的前提下放置双J管,2周后成功进镜。329例软镜成功进镜后寻及结石（329/338,97.3%）,其中306例成功碎石（306/329,93.0%）,下盏结石碎石成功率78.0%（32/41）,低于中上盏肾盂内结石的碎石成功率95.1%（274/288）（χ2=13.601,P=0.000）。4周后总结石排净率为87.6%（296/338）,肾中上盏及肾盂内结石术后排净率为90.1%（264/293）,肾下盏结石术后结石排净率为71.1%（32/45）,两者差异有显著性（χ2=12.929,P=0.000）。无输尿管穿孔和出血。平均手术时间为35min（12～55min）。术后肾绞痛11例。无菌血症及急性肾功能不全。术后肉眼血尿1～2天内消失。结论输尿管软镜结合FREDDY激光或钬激光是处理〈20mm肾结石的安全有效的手段。肾中上盏及肾盂内结石较肾下盏结石寻及率高,碎石成功率高,结石排净率高。一期输尿管镜进镜困难的患者可在成功留置双J管2周后二期行输尿管软镜碎石术。     

输尿管软镜钬激光碎石术治疗合并临床症状的肾盏憩室结石

目的 探讨输尿管软镜钬激光碎石术治疗合并临床症状的肾盏憩室结石的安全性及有效性. 方法 回顾性分析2008年1月至2010年12月输尿管软镜钬激光碎石术治疗23例合并临床症状的肾盏憩室结石患者资料.男15例,女8例.年龄23～68岁,平均44岁.主要特点为腰痛、血尿,尿路感染.10例曾行ESWL治疗,其中l例曾行2次ESWL.23例均为单侧肾盏憩室结石,结石位于肾上极11例,中部9例,下极3例.成堆泥沙样多发结石19例,单发结石4例.结石最大直径18.9 mm.术前1周均留置双J管,均行IVU及双肾CT检查.静脉复合麻醉下行输尿管软镜钬激光碎石术,留置输尿管扩张鞘,置入输尿管软镜抵达肾盂,寻及憩室开口,必要时用钬激光切开憩室颈部,憩室内大部分结石呈泥沙样聚集,小部分结石较大,予以钬激光碎石,结石碎屑随灌洗液冲出或用套石篮取出. 结果 本组23例均顺利置入输尿管软镜,一次进镜成功率100％.22例顺利寻及憩室结石,1例术中未寻及憩室开口改行PCNL,手术顺利.碎石成功20例(87.0％),术后无结石残留15例(65.3％).残留结石＜4 mm者5例;3例碎石失败者结石残块≥4 mm.平均手术时间60min,术后平均住院日3.5d.手术无并发症发生.术后随访6～12个月,患者症状均消失,未见结石复发. 结论 输尿管软镜钬激光碎石术治疗合并临床症状的肾盏憩室结石安全、有效,可作为临床首选治疗方法.     

双频双脉冲激光治疗输尿管结石失败原因分析

目的:探讨输尿管硬镜下双频双脉冲激光治疗输尿管结石失败原因。方法:对25例输尿管硬镜下双频双脉冲激光治疗输尿管结石失败患者的临床资料进行分析。结果:25例患者术中19例结石回漂、移位进入肾盂,无法寻见结石;3例输尿管扭曲或狭窄,进镜困难而放弃;3例因输尿管开口异常,置镜失败而终止手术。结论:结石回漂入肾盂、输尿管扭曲或狭窄、输尿管开口异常是手术失败的主要原因。合适病例的选择,套石篮的应用,冲洗速度的调整,碎石时激光纤维的位置是手术成功的关键。     

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.     

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.