原位回结肠新膀胱术后尿瘘的护理

目的 探讨原位回结肠新膀胱术后并发尿瘘的护理方法.方法 回顾性分析25例原位回结肠新膀胱患者的临床资料,总结术后尿瘘的类型、表现、原因和护理经验,包括尿瘘的护理、合理使用抗生素、营养支持疗法及心理护理.结果 原位回结肠新膀胱术后尿瘘5例,保守治疗后瘘口均愈合出院.结论 尿瘘是原位回结肠新膀胱术后常见的并发症之一,临床应以预防为主,术后做好引流管护理是关键.     

骨盆倾斜度异常产妇分娩体位干预效果观察

目的 探讨原位回结肠新膀胱术后并发尿瘘的护理方法。方法 回顾性分析25例原位回结肠新膀胱患者的临床资料，总结术后尿瘘的类型、表现、原因和护理经验，包括尿瘘的护理、合理使用抗生素、营养支持疗法及心理护理。结果 原位回结肠新膀胱术后尿瘘5例，保守治疗后瘘口均愈合出院。结论 尿瘘是原位回结肠新膀胱术后常见的并发症之一，临床应以预防为主，术后做好引流管护理是关键。     

可控性尿流改道与原位肠代膀胱的临床应用研究

目的:为膀胱全切术后的患者提供更好的控尿术式。方法:回顾性分析1998～2010年间28例可控性尿流改道(可控性回结肠膀胱)和21例原位肠代膀胱的并发症发生率及其对患者生活质量的影响。可控性回结肠膀胱组前9例行Indiana术式,后19例行改良的Indiana术式。原位肠代膀胱组采用乙状结肠或"W"形回肠纵行剖开制成贮尿囊。结果:本研究组49例均获得随访,随访时间6个月～12年。可控性回结肠膀胱组28例自行清洁导尿,间隔时间90～270min,平均240min。原位肠代膀胱组21例在腹压的辅助下自行排尿,排尿间隔时间150～240min,平均195min。可控性回结肠膀胱组中22例感觉生活满意或基本满意(78.6%),6例感觉生活不便(21.4%);9例出现并发症(32.1%)。原位肠代膀胱组中19例患者感觉生活满意(90.5%),2例感觉不满意(9.5%),均为压力性尿失禁;3例出现并发症(14.3%)。结论:原位肠代膀胱患者的生活质量优于可控性回结肠膀胱,术后并发症方面,原位肠代膀胱组患者并发症明显小于可控性回结肠膀胱组。     

膀胱全切原位W形回肠代膀胱术120例临床分析

目的 探讨膀胱全切原位W形回肠代膀胱术优缺点。方法120例男性膀胱癌患者,其中浸润性膀胱移行细胞癌99例,移行细胞癌伴部分鳞化8例,移行细胞癌伴腺癌及鳞癌3例,腺癌6例,鳞癌4例,均行膀胱全切原位W形回肠代膀胱术。膀胱全切采用顺行、逆行相结合的方法。截取末段回肠,排列成W形,褥式缝合制作储尿袋。输尿管以乳头法包埋术种植。结果手术时间,前50例为210-300mim,平均270min;后70例为110-205min,平均143min。术后9l例获得随访,随访2—88个月,平均30个月,85例白天可控制排尿,其中71例夜间可控制排尿。9例术后发生输尿管扩张,7例合并轻度肾积水,2例合并中度肾积水,2例肾功能轻度异常。45例行膀胱造影仅1例发生右侧输尿管返流。术后3个月复查出现低血钾者6例,余85例血电解质均在正常范围。20例患者行尿动力检查,尿流曲线呈持续型12例,间歇型8例;膀胱尿道造影显示尿流持续型代膀胱颈口呈漏斗形,排尿时开放良好,而尿流间歇形代膀胱颈口不呈漏斗形或排尿时颈口开放欠佳。结论膀胱全切原位W形回肠代膀胱术手术时间短,操作简单,出血少,并发症少,原位W形回肠代膀胱有较好的储尿和排尿功能,电解质紊乱发生率低。     

原位可控回结肠代膀胱术疗效总结

目的 回顾分析膀胱全切术后原位回结肠代膀胱术的疗效及并发症.方法 对52例膀胱癌患者行膀胱全切,原位回结肠代膀胱术,术后对患者排尿情况、肾功能、术后近期及远期并发症等进行随访.结果 45例患者获随访,随访时间3～146个月,平均42个月.术后6个月白天可控排尿38例,夜间可控排尿35例.3例(6.7%)术后6～15个月死于肿瘤盆腔复发或转移.2例(4.4%)于术后18、22个月尿道肿瘤复发,其中1例半年后死亡.5例(11.1%)术后3年内死于非肿瘤原因.术后近期和远期并发症发生率分别为17.8%(8例)和24.4%(11例).术后12个月2例患者出现肾功能轻度异常,血尿素氮为7.2、11.8 mmol/L,血肌酐为137、168 μmol/L.结论 原位可控回结肠代膀胱术无明显代谢紊乱及肾功能损害,具有良好的排控能力,手术并发症大多可临床治愈,是一种较为理想的尿流改道术式.     

膀胱

钬激光腔内治疗成人输尿管口囊肿（附5例报告）；带蒂腹膜片膀胱扩大成形术治疗；膀胱全切术后原位回盲肠膀胱与可控盲结肠膀胱患者远期生活质量比较；糖尿病性膀胱功能损害的尿动力学分析；膀胱癌组织中程序性死亡配体-1的表达及其意义     

原位肠代膀胱术远期疗效评价(附266例报告)

目的 总结评价原位肠代膀胱术的远期临床效果。方法 对1991-2003年266例因膀胱癌行膀胱全切手术患者资料进行分析。Hautmann回肠原位代膀胱术206例，Reddy原位结肠代膀胱术60例。131例患者在原标准术式基础上作了手术技术改进。总结手术改进前后患者控尿率和并发症发生率等。结果 获完整随访患者225例。回肠代膀胱术改进前后男性平均随访时间62（44-146）个月和38（4-67）个月；结肠原位代膀胱手术改进前后患者平均随访时间为62（51-131）个月和34（5-67）个月。手术改进可提高男性术后夜间可控率（P〈0．05），女性改善不明显（P〉0．05），总的近期和远期并发症发生率为13．8％和19．6％。男性肿瘤尿道复发9例（4％），女性无复发。结论 原位尿流改道术的远期临床疗效满意，并发症发生率低。手术技术改进可提高男性患者的夜间控尿率。     

双U形回肠代膀胱术的初步研究(附20例报告)

目的　改良回肠代膀胱成形方法 ,更好地解决膀胱全切术后贮尿和排尿问题。　方法　 2 0例膀胱癌患者行膀胱全切后 ,采用双U形方法作原位回肠代膀胱。于对系膜缘剖开肠管 ,肠片左右U形排列 ,连续缝合内侧缘 ;上下U形对折缝合成球形膀胱 ,上下U形缝合前行输尿管新膀胱再植和新膀胱尿道吻合。　结果　成形手术时间 (90± 15 )min。无严重并发症 ,无围手术期或术后早期死亡。术后随访 6～ 4 8个月 ,平均 2 5个月。患者控尿、排尿满意 ,2 0例 (10 0 % )白天控尿 ,夜间轻度尿失禁或遗尿 6例 (30 % ) ;1例男性患者出现排尿困难 ,行TUR解除。贮尿囊容量 2 5 0～ 4 5 0ml,平均 340ml,剩余尿 0～ 4 0ml。　结论　双U形回肠代膀胱术操作简便 ,新膀胱容量大、压力低 ,术后并发症发生率低。     

女性保留内生殖器膀胱全切原位回肠新膀胱尿流改道术的临床疗效

目的:探讨女性保留内生殖器膀胱全切患者行原位回肠新膀胱尿流改道术的临床疗效。方法:回顾性分析我院2005年7月~2012年5月48例女性膀胱肿瘤患者的临床资料,均采取保留内生殖器的膀胱全切术并行原位回肠新膀胱尿流改道术。48例患者中移行细胞癌46例,腺癌2例;原发肿瘤32例,复发性肿瘤16例;多发性非肌层侵犯肿瘤17例,肌层浸润性膀胱肿瘤31例。结果:48例患者的平均手术时间260(210~360)min,平均输血量280(0~1200)ml。术后47例患者获得随访,随访6~84个月,平均36个月。术后12个月白天控尿率为97.9%(46/47),夜间控尿率为93.6%(44/47)。新膀胱尿道吻合口漏3例。术后6个月IVU检查输尿管狭窄2例。无子宫、子宫附件及阴道转移复发。结论:对于符合适应证的女性膀胱癌患者,保留内生殖器、阴道前壁、自主神经及完整尿道,行膀胱全切并行原位回肠新膀胱尿流改道术,临床疗效满意,术后患者生活质量高,可作为广泛开展的术式。     

女性全膀胱切除原位回肠新膀胱术20例报告

目的探讨女性全膀胱切除原位回肠新膀胱术的技术改进及临床应用价值。方法 2004年1月至2009年1月,对20例女性膀胱肿瘤患者行全膀胱切除原位回肠新膀胱术,其间进行了系列改良探索,包括保留子宫、卵巢及附件的膀胱全切;保留完整尿道、阴道及自主神经的膀胱全切;腹膜外顺行切除膀胱;手助拔针邻边全层连续褥式缝合制作＂W＂回肠新膀胱;用直线切割吻合器恢复肠道连续性;用自制引导探子引导新膀胱与尿道吻合等。随访观察肿瘤控制、并发症及排尿控尿功能。结果手术时间平均330min,术中平均出血560ml。术后2～4周拔除尿管,患者排尿通畅。18例获得随访,平均随访时间38个月,术后12个月内恢复昼夜尿控分别为94.4%和88.9%,新膀胱容量平均330ml,蹲式手辅腹压排尿下,最大尿流率平均24.6ml/s,残余尿量0～25ml。无肿瘤复发及种植转移。结论经初步观察,女性膀胱肿瘤患者行膀胱全切,可尝试保留子宫、卵巢、附件和完整的尿道、阴道;全膀胱切除原位回肠新膀胱术较适于女性患者;所行系列改良可降低手术难度,减少并发症,在肿瘤根治的同时利于控尿恢复。     

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.