开腹手术和腹腔镜手术治疗老年胆囊及胆总管结石的疗效分析

目的 比较腹腔镜胆囊切除+胆总管切开探查取石术和传统开腹胆囊切除+胆总管开探查取石术的临床效果.方法 2009年3月到2012年12月我院52例老年胆总管结石患者分两组,组腹腔镜25例行腹腔镜胆切除+胆总管切开取石术;27例传统开腹胆囊切除+胆总管切开取石术.统计手术时间,术后住院时间,术后发症.结果 腹腔镜组具有住院时间短,术中出血少.结论 腹腔镜胆总管切开取石术完全能达到传统开腹胆道切开取石术的效果,并具有创伤小,痛苦少,恢复快的优点.     

腹腔镜与传统开腹手术治疗胆总管结石的临床应用比较

目的比较腹腔镜胆囊切除＋胆总管切开探查取石术和传统开腹胆囊切除＋胆总管切开探查取石术的临床效果和医疗费用。方法55例胆总管结石患者分两组,A组25例行腹腔镜胆囊切除＋胆总管切开取石术;B组30例行传统开腹胆囊切除＋胆总管切开取石术。统计手术时间,术后开始下床活动时间,术后胃肠功能恢复时间,术后住院时间,术后并发症和总住院费用。结果两组患者都顺利完成手术,术后两组各有1例患者胆道造影残留结石,两组手术时间无显著差异,A组患者术后下床活动时间、胃肠功能恢复时间较B组患者早,术后A组住院时间较B组短,住院费用A组较B组增多。结论腹腔镜胆总管切开取石术完全能达到传统开腹胆道切开取石术的效果,并具有创伤小,痛苦少,恢复快的优点,是治疗胆总管结石的理想手术方式之一。     

三种术式行胆总管切开取石术的对比研究

目的:比较完全腹腔镜手术、小切口手术及开腹手术行胆总管切开取石术的临床效果.方法:回顾性分析近5年胆囊结石合并胆总管结石手术治疗的217例患者的临床资料,其中,行腹腔镜胆囊切除(LC)+腹腔镜下胆总管切开取石术( LCBDE) 69例(腹腔镜组);行LC+小切口胆总管切开取石术85例(小切口组);行开腹胆囊切除+胆总管切口取石术63例(开腹组).对比3组间的相关临床指标.结果:腹腔镜组、小切口组在术中出血量、术后肠道功能恢复时间、术后疼痛、并发症发生率以及术后住院时间上明显优于开腹组(均P＜0.05),小切口组在手术时间及气腹时间上明显少于腹腔镜组(均P＜0.05).结论:LCBDE及辅助小切口手术都具有创伤小、恢复快、痛苦少等优点.与LCBDE相比,小切口手术减少了手术时间及术中气腹时间,尤其适用于不能耐受长时间气腹及心肺功能较差的年老患者.     

不同方式行胆囊切除加胆总管切开取石术的比较

目的:比较常规腹腔镜手术、腹腔镜转小切口手术和开腹手术行胆囊切除术+胆总管切开取石术的临床效果。方法:回顾性分析近4年胆囊结石合并胆总管结石手术治疗的107例患者的临床资料,其中,腹腔镜组:腹腔镜胆囊切除术(LC)+腹腔镜下胆总管切开取石术(LCBDE)40例。小切口组:32例,包括行LC+LCBDE中转小切口胆道探查术、取石2例。开腹组:开腹胆囊切除+胆总管切口取石术35例。对比、分析3组的相关临床指标。结果:3组均无严重并发症。腹腔镜组、小切口组在术中出血、术后肛门排气时间、术后疼痛、感染等并发症发生率以及术后住院时间方面要优于开腹组(均P<0.05);小切口组手术时间比腹腔镜组短。结论:与开腹手术相比,LCBDE及小切口组具有创伤小、痛苦轻、恢复快、更美观等优点。但LCBDE组的适应证范围较开腹组窄,不适用于体质较差、心肺功能较差的年老患者以及不能耐受长时间气腹等患者。     

腹腔镜胆囊切除辅助小切口胆总管探查治疗胆囊结石合并胆总管结石的临床研究

目的 探讨腹腔镜胆囊切除辅助小切口胆总管探查治疗胆囊结石合并胆总管结石的诊治经验及应用价值.方法 回顾性分析142例患者的临床资料,142例分为腹腔镜胆囊切除+小切口辅助胆总管探查术组(A组)、腹腔镜胆囊切除+胆总管探查术组(B组)和开腹手术组(C组),比较三组患者的手术时间、术中出血量、术后肠功能恢复时间、腹腔引流量、住院时间及并发症发生率.结果 A组患者手术时间与B组比较差异有统计学意义(P<0.05),肠功能恢复时间、住院时间与C组比较差异有统计学意义(P<0.05).结论 小切口辅助腹腔镜胆囊切除合并胆总管结石的治疗安全可行,但应根据情况采用个体化的治疗方法.     

LC辅助小切口胆总管探查取石治疗复杂肝胆管结石的临床应用

探讨腹腔镜胆囊切除(LC)辅助小切口胆总管探查取石在复杂肝胆管结石中的应用。168例复杂肝胆管结石患者按照患者及家属知情意愿分为对照组与观察组,每组84例。对照组行LC+腹腔镜胆总管探查取石术(LCBDE),观察组行LC辅助小切口胆总管探查取石术。在术中失血量、住院时间、术后卧床时间、肛门排气时间以及并发症方面,观察组与对照组比较,差异无统计学意义(P0.05);观察组手术时间显著少于对照组(t=5.927,P0.01)。复杂肝胆管结石的治疗可首先考虑LC+LCBDE;对手术失败者,肝胆管结石较多且大部分位于Ⅱ级胆管以上者,术前评估手术难度大、取石时间长者,胆总管直径1.0 cm者应直接选择腹腔镜下胆囊切除辅助小切口胆总管探查取石术。     

内镜联合腹腔镜与传统开腹手术治疗胆囊结石合并胆总管结石的临床比较

目的:探讨内镜联合腹腔镜治疗胆囊结石合并胆总管结石的临床疗效。方法:回顾分析2010年1月至2012年12月106例胆囊结石合并胆总管结石患者的临床资料,其中内镜联合腹腔镜手术(联合组)58例,开腹胆囊切除+胆总管探查术(开腹组)48例,对比两组患者术后恢复情况。结果:联合组术后通气时间、住院时间、住院费用显著优于开腹组(P<0.05);联合组术后5例发生并发症,开腹组发生12例,差异有统计学意义(χ2=5.232,P=0.022)。结论:内镜联合腹腔镜手术治疗胆囊结石合并胆总管结石安全、有效,具有患者创伤小、康复快的优点;但术者应准确掌握适应证、合理安排内镜下十二指肠乳头切开取石术与腹腔镜胆囊切除术的间隔时间。     

腹腔镜治疗胆总管结石116例诊治分析

目的探讨腹腔镜胆总管切开探查取石术治疗胆总管结石的临床效果及注意事项。方法对腹腔镜胆总管切开探查取石术治疗的116例胆总管结石患者的临床资料进行回顾性分析,并与同期98例行传统开腹胆囊切除胆总管切开取石、T管引流术治疗胆总管结石患者的临床资料进行比较分析。结果两组患者手术均获成功,患者术后恢复良好。LCBDE组与OCHTD组在术中出血量、肠蠕动恢复时间、术后住院日数、术后切口感染、肠梗阻等方面比较,差异有统计学意义（P〈0.05）。两组在手术时间、术后出血、术后胆瘘、腹腔脓肿、一次性结石清除率等方面比较,差异无统计学意义（P〉0.05）。结论腹腔镜胆总管切开探查取石术是安全、有效治疗胆总管结石的微创手术方法,可逐渐取代大部分传统开腹胆总管探查术。     

腹腔镜联合纤维胆道镜治疗胆囊胆总管结石

目的探讨腹腔镜联合胆道镜治疗胆囊结石胆总管结石的效果。方法将2005年6月—2009年6月收治的168例胆囊结石合并胆总管结石患者,随机抽取90例行腹腔镜胆囊切除+胆总管切开+胆道镜探查、取石T管引流术(联合腹腔镜组),另78例行开腹胆囊切除+胆总管切开取石T管引流术(对照组),对比分析两组的临床效果。结果开腹组并发症发生率高于联合组(P0.05),联合组住院时间、胃肠功能恢复时间均短于对照组(P0.05),两组手术时间、住院费用差异无统计学意义(P0.05)。结论与传统开腹手术相比,用腹腔镜联合胆道镜治疗胆囊胆总管结石具有创伤小、恢复快、住院时间短等优点,优于传统开腹手术。     

腹腔镜联合纤维胆道镜行胆总管切开取石一期缝合术临床观察

目的:探讨腹腔镜联合纤维胆道镜在胆总管切开取石行一期缝合的临床效果及应用价值。方法:选择2004年9月—2010年4月收治的胆囊结石合并胆总管结石86例患者,随机抽取42例行腹腔镜胆囊切除+胆总管切开取石行一期缝合胆总管作为观察组,与44例同期行开腹胆囊切除+胆总管切开取石T管引流作为对照组。两组术中均行纤维胆道镜探查胆总管。结果:两组在腹腔引流管引流留置时间、平均住院费用、平均出血量、胆瘘及残石率等无统计学意义(P>0.05),观察组在平均住院时间、术后肛门排气时间、下床活动时间、平均进食时间、术后疼痛及切口感染明显优于对照组(P<0.05)。结论:腹腔镜胆总管切开探查取石一期缝合胆总管是一种创伤小,住院时间短,术后恢复快,并发症少,跟传统开腹相比有一定的优势。     

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.     

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.     

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.     

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.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

缺氧对肾小管上皮细胞分泌外泌体的影响

目的    观察缺氧对肾小管上皮细胞分泌外泌体的影响,探讨外泌体在缺氧致肾脏损伤中的作用及机制。 方法    （1）常氧（21% O₂）及缺氧（1% O₂）分别处理大鼠肾小管上皮细胞（NRK-52E）48 h,收集细胞上清液并使用高速梯度离心法分离外泌体。采用透射电镜、纳米示踪分析、Western印迹、蛋白浓度定量鉴定并比较两组外泌体的基本特性。（2）在共培养实验中,以不同浓度（1、10、50、100、300 mg/L）的常氧外泌体、缺氧外泌体分别干预脂多糖（LPS）诱导的大鼠原代腹腔巨噬细胞,使用实时荧光定量PCR与酶联免疫吸附试验（ELISA）法分别检测巨噬细胞白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、诱导型氮氧化物合酶（iNOS）水平;使用Western印迹法检测巨噬细胞磷酸化（p）STAT/STAT及细胞因子信号传导抑制蛋白1（SOCS1）的蛋白表达;最后,使用实时荧光定量PCR法检测常氧外泌体与缺氧外泌体中炎性反应相关微RNA（microRNA,miR）的表达差异。 结果    （1）离心得到的囊泡具有外泌体典型的结构,粒径小于150 nm,表达外泌体标志蛋白CD63,说明分离得到外泌体。缺氧对肾小管上皮细胞分泌的外泌体形态、粒径分布比例无明显影响,但提高了外泌体的分泌量。（2）缺氧外泌体相比于常氧外泌体促进了LPS诱导的M1型巨噬细胞IL-6、TNF-α、iNOS 的表达和分泌（均P＜0.01）,同时提高STAT的磷酸化水平并减少SOCS1的蛋白表达（均P＜0.01）;对炎性反应相关microRNA检测发现缺氧外泌体中miR-155、miR-27a表达量较常氧外泌体明显升高（P＜0.05）。 结论    缺氧可改变外泌体的生物学功能,表现为协同促进LPS诱导的M1型巨噬细胞的表型转化,这可能是慢性肾脏病微炎性反应状态持续的原因之一。     

In Vitro Function and Durability Assessment of a Novel Polyurethane Heart Valve Prosthesis

Abstract While flexible-leaflet, central-flow prosthetic heart valves promise relief from anticoagulation therapy, they continue to be restricted by inadequate durability. In consequence, a novel trileaflet valve, made entirely from polyurethane, has been developed. A batch of 6 consecutively manufactured polyurethane valves was subjected to hydrodynamic function and accelerated fatigue testing. Computerized data acquisition and control systems have been introduced to improve valve testing methodologies. In terms of hydrodynamic function, the polyurethane valve demonstrates transvalvular pressure gradients similar to those for a bioprosthetic valve (Carpentier-Edwards) and levels of retrograde flow significantly less than those for either the bioprosthetic valve or a bileaflet mechanical valve (St Jude Medical). The equivalent of 10 years of cycling without failure has been exceeded by all 6 polyurethane valves in accelerated fatigue tests with 2 valves remaining intact after 674 million cycles (equivalent to approximately 17 years) in continuing tests. Highspeed photography revealed considerable differences in leaflet motion between valves cycled at accelerated and physiological rates.     

Negative pressure ventilation vs. spontaneous assisted ventilation during rigid bronchoscopy: A controlled randomised trial

Background: Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). Methods: Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre-and intra-operative arterial blood gases and O₂ flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. Results: Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 ± 1.8 (μg · kg^?1· h^?1 vs. 6.6 ± 4.8 μg · kg^?1· h^?1), a lower O₂ supply (3.3 ± 2.8 1/min vs. 11.6 ± 3.4 1/min), a shorter recovery time (5.4 ± 2.9 min vs. 9.8 ± 7.1 min) and no manually assisted ventilation (0 ± 0 vs. 1 ± 1.1 nd?/procedure). Intraoperative PaCO₂ was higher in the SAV (8.1 ± 1.3 kPa) than in the INPV group (5.0 ± 1.6 kPa) and intraoperative pH differed in the two groups (7.26 ± 0.05, SAV vs. 7.47 ± 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). Conclusions: As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces 02 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.